Publications by authors named "Stefano Siboni"

58 Publications

The semirecumbent position for high-resolution esophageal manometry. Results of a feasibility study.

Eur J Gastroenterol Hepatol 2021 Apr 9. Epub 2021 Apr 9.

Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy.

Objective: Normative values for high-resolution manometry (HRM) have been obtained with the patient lying supine. The aim of the study was to compare supine, semirecumbent and sitting positions during HRM in terms of variation in normative metrics, diagnostic yield, and patient's comfort.

Methods: A prospective, single-center feasibility study was planned in consecutive patients referred to the esophageal function laboratory. In each of the three positions, 10 consecutive 5 ml water swallows and three 10 ml multiple rapid swallows were administered. Validated reflux questionnaires were administered prior to the test, and a visual analogue scale (VAS) assessing the patient's comfort after the test.

Results: Twenty patients presenting with gastroesophageal reflux symptoms completed the study protocol. The intra-abdominal segment of the lower esophageal sphincter was significantly longer in the sitting position (P = 0.013), and the multiple rapid swallow distal contractile integral was lowest in the supine position (P = 0.012). The VAS comfort score did not significantly differ in the three body positions (P = 0.295). The concordance in the final diagnosis was 80% for semirecumbent vs. sitting (kappa = 0.15; P = 0.001), 70% for supine vs. sitting and 65.0% for semirecumbent vs. supine.

Conclusion: Compared to the supine position, both the semirecumbent and sitting position seems to provide similar advantages. HRM metrics and the final manometric diagnosis may be affected by body position, but complementary maneuvers, such are the rapid drink challenge, can resolve diagnostic discrepancies and improve the overall accuracy of the test.
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http://dx.doi.org/10.1097/MEG.0000000000002143DOI Listing
April 2021

Reference high-resolution manometry values after magnetic sphincter augmentation.

Neurogastroenterol Motil 2021 Mar 27:e14139. Epub 2021 Mar 27.

Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milan, Italy.

Background: Magnetic sphincter augmentation (MSA) is an innovative antireflux procedure that can improve lower esophageal sphincter (LES) competency and reduce symptoms of gastroesophageal reflux disease (GERD). Some patients report postoperative dysphagia. To date, no studies have described reference high-resolution manometry (HRM) values after MSA implantation.

Methods: High-resolution manometry was performed in patients free of dysphagia after MSA with or without concurrent crura repair. Reference values for all parameters of the Chicago Classification were defined as those between the 5th and 95th percentiles. The contribution of concurrent crura repair to LES competency and to reference values was also analyzed.

Key Results: Eighty-four patients met the study inclusion criteria. The upper limit of normality for integrated relaxation pressure (IRP) and intrabolus pressure (IBP) was 20.2 mmHg and 30.3 mmHg, respectively. Both variables were higher after MSA compared to normative Chicago Classification v3.0 values. The Distal Contractile Integral upper limit was in the range of normality. Patients undergoing crura repair had a significantly higher IRP (p = 0.0378) and lower GERDQ-A scores (p = 0.0374) and Reflux Symptom Index (p = 0.0030) compared to those who underwent MSA device implantation alone.

Conclusion & Inferences: This study provides HRM reference values for patients undergoing successful MSA implantation. Crural repair appears to be a key component of LES augmentation and is associated with improved clinical outcomes.
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http://dx.doi.org/10.1111/nmo.14139DOI Listing
March 2021

Esophageal Lipoma and Liposarcoma: A Systematic Review.

World J Surg 2021 Jan 7;45(1):225-234. Epub 2020 Oct 7.

Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, University of Milan, IRCCS Policlinico San Donato, 20133, Milan, Italy.

Background: Esophageal lipomatous tumors, also reported as fibrovascular polyp, fibrolipoma, angiolipoma, and liposarcoma, account for less than 1% of all benign mesenchymal submucosal tumors of the esophagus. Clinical presentation and therapy may differ based on location, size, and morphology. A comprehensive and updated systematic review of the literature is lacking.

Methods: A systematic review of the literature was performed according to PRISMA guidelines. Pubmed, Embase, Cochrane, and Medline databases were consulted using MESH keywords. Non-English written articles and abstracts were excluded. Sex, age, symptoms at presentation, diagnosis, tumor location and size, surgical approach and technique of excision, pathology, and morphology were extracted and recorded in an electronic database.

Results: Sixty-seven studies for a total of 239 patients with esophageal lipoma or liposarcoma were included in the qualitative analysis. Among 176 patients with benign lipoma, the median age was 55. The main symptoms were dysphagia (64.2%), transoral polyp regurgitation (32.4%), and globus sensation (22.7%). The majority of lipomas (85.7%) were intraluminal polyps, with a stalk originating from the upper esophagus. Overall, 165 patients underwent excision of the mass through open surgery (65.5%), endoscopy (27.9%), or laparoscopy/thoracoscopy (3.6%). Only 5 (3%) of patients required esophagectomy. Of the 11 untreated patients with an intraluminal polyp, 7 died from asphyxia. Overall, liposarcoma was diagnosed in 63 patients, and 12 (19%) underwent esophagectomy.

Conclusion: Esophageal lipomatous tumors are rare but potentially lethal when are intraluminal and originate from the cervical esophagus. Modern radiological imaging has improved diagnostic accuracy. Minimally invasive transoral and laparoscopic/thoracoscopic techniques represent the therapeutic approach of choice.
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http://dx.doi.org/10.1007/s00268-020-05789-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752877PMC
January 2021

Endoscopic stapling versus laser for Zenker diverticulum: a retrospective cohort study.

Eur Arch Otorhinolaryngol 2020 Sep 7. Epub 2020 Sep 7.

Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy.

Purpose: Despite the evolution of the endoscopic techniques for the treatment of symptomatic Zenker diverticulum, comparative studies are lacking. Aim of this observational study was to compare safety, efficacy, and outcomes of endoscopic stapling (ES) versus Laser (EL).

Methods: A prospectively collected database of patients who underwent treatment for Zenker diverticulum at a single institution was reviewed. Consecutive patients treated by ES or EL were included in the study. Demographic data, presenting symptoms, diverticulum characteristics, and intra- and postoperative data were analyzed. The Functional Outcome Swallowing Scale (FOSS) and MD Anderson Dysphagia Inventory (MDADI) questionnaires were administered to assess severity of dysphagia and quality of life before and after treatment.

Results: Between March 2017 and September 2018, 36 patients underwent ES or EL. In the TL group (n = 19), the diverticulum size was smaller compared to the EL group (n = 17) (p = 0.002). Two perforations occurred in the EL group, one treated conservatively and the other requiring drainage of a mediastinal abscess. At a median follow-up of 16 months, symptoms improved in both groups but the number of patients with a postoperative FOSS score ≥ 2 significantly decreased only after EL (p < 0.001). The scores of all items of the MDADI questionnaire significantly increased in both groups, but the average delta values were greater in the EL patients (p < 0.001).

Conclusions: Both TL and ES are effective treatment options for Zenker diverticulum. Postoperative quality of life was significantly higher in patients undergoing EL compared to ES.
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http://dx.doi.org/10.1007/s00405-020-06346-4DOI Listing
September 2020

Six to 12-year outcomes of magnetic sphincter augmentation for gastroesophageal reflux disease.

Sci Rep 2020 08 13;10(1):13753. Epub 2020 Aug 13.

Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.

The magnetic sphincter augmentation (MSA) device has been proven safe and effective in controlling typical reflux symptoms and esophageal acid exposure for up to 6-year follow-up. Longer term outcomes have not been reported yet. A prospectively maintained database was reviewed to assess long-term safety and efficacy of the laparoscopic MSA procedure at a single referral center. Gastro-Esophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), use of proton-pump inhibitors (PPI), and esophageal acid exposure were compared to baseline. Favorable outcomes were defined as ≥ 50% improvement of GERD-HRQL total score and PPI discontinuation. Between March 2007 and March 2020, 335 patients met the study inclusion criteria, and 124 of them were followed from 6 to 12 years after surgery (median 9 years, IQR 2). Mean total GERD-HRQL score significantly improved from 19.9 to 4.01 (p < 0.001), and PPI were discontinued by 79% of patients. The mean total percent time with pH < 4 decreased from 9.6% at baseline to 4.1% (p < 0.001), with 89% of patients achieving pH normalization. Independent predictors of a favorable outcome were age at intervention < 40 years (OR 4.17) and GERD-HRQL score > 15 (OR 4.09). We confirm long-term safety and efficacy of MSA in terms of symptom improvement, decreased drug dependency, and reduced esophageal acid exposure.
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http://dx.doi.org/10.1038/s41598-020-70742-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426413PMC
August 2020

Minimally invasive approach to esophageal lipoma.

J Surg Case Rep 2020 Jul 31;2020(7):rjaa123. Epub 2020 Jul 31.

University of Milan, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, Milano, Italy.

Esophageal lipoma is a rare neoplasm with heterogeneous and sometimes life-threatening clinical presentation. We report the case of two patients, a 77-year-old man and a 69-year-old woman presenting with heartburn and dysphagia, and with recurrent vomiting and asphyxia, respectively. Upper gastrointestinal endoscopy and computed tomography were highly suggestive of the diagnosis of esophageal lipoma and identified an intramural and an intraluminal pedunculated mass originating, respectively, from the distal and the cervical esophagus. The first patient was treated by laparoscopic transhiatal enucleation and the second by transoral endoscopic resection under general anesthesia. Both had an uneventful postoperative course and were discharged home on postoperative day 2. Minimally invasive excision of esophageal lipoma is feasible and effective. It may be life-saving in patients with pedunculated tumors who suffer from intermittent regurgitation of a bulky polypoid mass in the mouth causing asphyxia.
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http://dx.doi.org/10.1093/jscr/rjaa123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7394138PMC
July 2020

Effect of Body Position on High-resolution Esophageal Manometry Variables and Final Manometric Diagnosis.

J Neurogastroenterol Motil 2020 07;26(3):335-343

Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy.

Background/aims: According to the Chicago classification version 3.0, high-resolution manometry (HRM) should be performed in the supine position. However, with the patient in the upright/sitting position, the test could more closely simulate real-life behavior and may be better tolerated. We performed a systematic review of the literature to search whether the manometric variables and the final diagnosis are affected by positional changes.

Methods: A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies published in English that compared HRM results in different body positions were included. Moreover, the change in diagnosis of esophageal motility disorders according to the shift of body position was investigated.

Results: Seventeen studies including 1714 patients and healthy volunteers met the inclusion criteria. Six studies showed a significant increase in lower esophageal sphincter basal pressure in the supine position. Integrated relaxation pressure was significantly higher in the supine position in 10 of 13 studies. Distal contractile index was higher in the supine position in 9 out of 10 studies. One hundred and fifty-one patients (16.4%) out of 922 with normal HRM in the supine position were diagnosed with ineffective esophageal motility (IEM) when the test was performed in the upright position ( < 0.001).

Conclusions: Performing HRM in the upright position affects some variables and may change the final manometric diagnosis. Further studies to determine the normal values in the sitting position are needed.
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http://dx.doi.org/10.5056/jnm20010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329148PMC
July 2020

Esophageal foreign bodies: observational cohort study and factors associated with recurrent impaction.

Eur J Gastroenterol Hepatol 2020 07;32(7):827-831

Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato.

Background And Aim: Esophageal foreign bodies, including food bolus impaction, represent a common clinical problem. The prevalence of underlying esophageal disease depends on study design and degree of suspicion of a structural or functional esophageal abnormality. Aim of this study was to analyze factors associated with recurrent impaction.

Methods: The prospectively collected database at a University Hospital and Swallowing Center was reviewed from January 2012 to June 2019 to identify all patients admitted for esophageal foreign bodies. Patients who underwent an emergency endoscopic procedure represented the final study sample. Patient characteristics, including history of previous esophageal foreign bodies, and type of endoscopic procedure were collected.

Results: Sixty-five patients, 41 males and 24 females with a median age of 59 years, underwent emergency endoscopy for esophageal foreign bodies during the study period. Food bolus was the most common foreign body (n = 43, 66%). Flexible endoscopy was successful in retrieving or pushing the foreign bodies in the stomach in 91% of patients. In 54% of patients, impaction was secondary to an underlying esophageal disorder, which was previously unrecognized in half of them. Recurrent impaction was more common in patients with esophageal disease (P < 0.011). Surgical therapy was required in 4 patients (6.1%).

Conclusions: Food bolus impaction is a common sentinel event in patients with underlying esophageal disease and is associated with recurrent impaction. Diagnostic endoscopy with biopsies should possibly be performed at the first episode of impaction. Patients with negative biopsies should undergo barium swallow study and high-resolution esophageal manometry.
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http://dx.doi.org/10.1097/MEG.0000000000001717DOI Listing
July 2020

Surface softening in palladium nanoparticles: effects of a capping agent on vibrational properties.

Nanoscale 2020 Mar;12(10):5876-5887

Department of Civil, Environmental and Mechanical Engineering, University of Trento, Via Mesiano 77, 38123 Trento, Italy.

The presence of a capping agent (CTAB) on Pd nanoparticles produces a strong static disorder in the surface region. This results in a surface softening, which contributes to an overall increase in the Debye-Waller coefficient measured by X-ray powder diffraction. Molecular dynamics and density functional theory simulations show that the adsorption-induced surface disorder is strong enough to overcome the effects of nanoparticle size and shape.
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http://dx.doi.org/10.1039/d0nr00182aDOI Listing
March 2020

Transthyretin at Admission and Over Time as a Marker for Clinical Outcomes in Critically Ill Trauma Patients: A Prospective Single-Center Study.

World J Surg 2020 01;44(1):115-123

Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, 1200 N. State St, Inpatient Tower (C) - Rm C5L100, Los Angeles, CA, 90033, USA.

Background: Transthyretin (TTR) has been described as a predictor for outcomes in medical and surgical patients. However, the association of TTR on admission and over time on outcomes has not yet been prospectively assessed in trauma patients.

Methods: This is a prospective observational study including trauma patients admitted to the intensive care unit (ICU) of a large Level I trauma center 05/2014-05/2015. TTR levels at ICU admission and all subsequent values over time were recorded. Patients were observed for 28 days or until hospital discharge. The association of outcomes and TTR levels at admission and over time was assessed using multivariable regression and generalized estimating equation (GEE) analysis, respectively.

Results: A total of 237 patients with TTR obtained at admission were included, 69 of whom had repeated TTR measurements. Median age was 40.0 years and median ISS 16.0; 83.1% were male. Below-normal TTR levels at admission (41.8%) were independently associated with higher in-hospital mortality (p = 0.042), more infectious complications (p = 0.032), longer total hospital length of stay (LOS) (p = 0.013), and ICU LOS (p = 0.041). Higher TTR levels over time were independently associated with lower in-hospital mortality (p = 0.015), fewer infections complications (p = 0.028), shorter total hospital and ICU LOS (both p < 0.001), and fewer ventilator days (0.004).

Conclusions: In critically ill trauma patients, below-normal TTR levels at admission were independently associated with worse outcomes and higher TTR levels over time with better outcomes, including lower in-hospital mortality, less infectious complications, shorter total hospital and ICU LOS, and fewer ventilator days. Based on these results, TTR may be considered as a prognostic marker in this patient population.
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http://dx.doi.org/10.1007/s00268-019-05140-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222866PMC
January 2020

High-resolution manometry findings after Linx procedure for gastro-esophageal reflux disease.

Neurogastroenterol Motil 2020 03 21;32(3):e13750. Epub 2019 Oct 21.

Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato, San Donato Milanese, Italy.

Background: Magnetic sphincter augmentation with the Linx system is a novel laparoscopic procedure for the treatment of gastro-esophageal reflux disease (GERD). Only few data are available regarding the impact of Linx on high-resolution manometry (HRM) variables.

Methods: The prospectively collected database of patients who underwent Linx procedure at a single institution was queried. All patients who completed pre- and postoperative HRM, GERD health-related quality of life (GERD-HRQL) questionnaire, and functional outcome swallowing scale (FOSS) questionnaire were included in the study.

Key Results: Forty-five out of 304 patients were included. At a median follow-up of 12 months (IQR 10) after surgery, a statistically significant increase of lower esophageal sphincter (LES) total length (P = .002), intra-abdominal length (P = .001), integrated relaxation pressure (IRP), intrabolus pressure (IBP), and esophagogastric contractile integral (EGJ-CI) was noted (P < .001). Distal esophageal amplitude (P = .004), mean distal contractile integral (DCI) (P < .001), post multiple repeated swallows DCI (P = .001), and the percent of normal peristalsis increased (P = .040). All patients were relieved of reflux symptoms. Ineffective esophageal motility reversed to normal in 36% of patients after surgery. The only factor significantly associated with postoperative dysphagia was preoperative dysphagia (P = .006). Postoperatively, a significant correlation between IRP and DCI (r = 0.361 and P = .019) and between IBP and DCI (r = 0.443 and P = .003) was found.

Conclusions And Inferences: The Linx procedure had a remarkable effect on esophageal motility in the short-term follow-up. It appears that the overall postoperative increase of IRP and IBP may justify the higher DCI values. Preoperative dysphagia was the only factor associated with postoperative dysphagia.
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http://dx.doi.org/10.1111/nmo.13750DOI Listing
March 2020

Magnetic Sphincter Augmentation After Gastric Surgery.

JSLS 2019 Oct-Dec;23(4)

Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy.

Background: Persistent or de novo gastroesophageal reflux disease (GERD) may be a significant clinical issue after gastric/bariatric surgical procedures. We investigated the effect of magnetic sphincter augmentation (MSA) in the treatment of GERD after previous gastric/bariatric surgery.

Database: We conducted a systematic review according to the Preferred Reporting Items For Systematic Reviews and Meta-analyses statement. We searched multiple databases (PubMed, Cochrane, Embase, Scopus) up to May 2019. We also queried the prospectively collected database of patients who underwent MSA at our tertiary-care hospital and compared postsurgical to naïve patients operated during the same time period.

Results: Seven studies (3 case series and 4 case reports), for a total of 35 patients, met the inclusion criteria in the systematic review. The most common index operation was a bariatric procedure, either sleeve gastrectomy or Roux-en-Y gastric bypass. After MSA implant, the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) score significantly improved compared to baseline ( = .005). Two patients (5.7%) required laparoscopic device removal. In the local institutional cohort series of 67 patients treated by MSA, the prevalence of preoperative grade B esophagitis, operative time, size of MSA, and length of stay were greater in patients with prior gastric surgery compared to naïve patients.

Conclusions: MSA is a safe, simple, and standardized antireflux procedure. It is also feasible in patients with refractory GERD following gastric/bariatric surgery. Further prospective and comparative studies are needed to validate the preliminary clinical experience in this subset of patients.
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http://dx.doi.org/10.4293/JSLS.2019.00035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785249PMC
March 2020

The Notched Stick, an ancient vibrot example.

PLoS One 2019 26;14(6):e0218666. Epub 2019 Jun 26.

Department of Civil, Environmental and Mechanical Engineering (DICAM), University of Trento, Trento, Italy.

An intriguing simple toy, commonly known as the Notched Stick, is discussed as an example of a "vibrot", a device designed and built to yield conversion of mechanical vibrations into a rotational motion. The toy, that can be briefly described as a propeller fixed on a stick by means of a nail and free to rotate around it, is investigated from both an experimental and a numerical point of view, under various conditions and settings, to investigate the basic working principles of the device. The conversion efficiency from vibration to rotational motion turns out to be very small, or even not detectable at all, whenever the propeller is tightly connected to the stick nail and perfectly axisymmetrical with respect to the nail axis; the small effects possibly observed can be ascribed to friction forces. In contrast, the device succeeds in converting vibrations into rotations when the propeller center of mass is not aligned with the nail axis, a condition occurring when either the nail-propeller coupling is not tight or the propeller is not completely axisymmetrical relative to the nail axis. The propeller rotation may be induced by a process of parametric resonance for purely vertical oscillations of the nail, by ordinary resonance if the nail only oscillates horizontally or, finally, by a combination of both processes when nail oscillations take place in an intermediate direction. Parametric resonance explains the onset of rotations also when the weight of the propeller is negligible. In contrast with what is commonly claimed in the literature, the possible elliptical motion of the nail, due to a composition of two harmonic motions of the same frequency imposed along orthogonal directions, seems unnecessary to determine the propeller rotation.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0218666PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594746PMC
February 2020

Esophageal emergencies: WSES guidelines.

World J Emerg Surg 2019 31;14:26. Epub 2019 May 31.

3Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy.

The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.
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http://dx.doi.org/10.1186/s13017-019-0245-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544956PMC
September 2019

Clinical Outcomes of Minimally Invasive Enucleation of Leiomyoma of the Esophagus and Esophagogastric Junction.

J Gastrointest Surg 2020 03 2;24(3):499-504. Epub 2019 Apr 2.

Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy.

Objective: Minimally invasive enucleation is the treatment of choice in symptomatic patients with esophageal leiomyoma. Comprehensive long-term follow-up data are lacking. Aim of this study was to review the clinical outcomes of three procedures for enucleation of leiomyoma of the esophagus and esophagogastric junction.

Methods: A single institution retrospective review was performed using a prospectively collected research database and individual medical records. Demographics, presenting symptoms, use of proton-pump inhibitors (PPI), tumor location and size, treatment modalities, and subjective and objective clinical outcomes were recorded. Barium swallow and upper gastrointestinal endoscopy were routinely performed during the follow-up. Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) and Short-Form 36 questionnaires were used to compare quality of life before and after treatment.

Results: Between 2002 and 2017, 35 patients underwent minimally invasive leiomyoma enucleation through thoracoscopy (n = 15), laparoscopy (n = 15), and endoscopy (n = 5). The overall morbidity rate was 14.3% and there was no mortality. All patients had a minimum of 1-year follow-up. The median follow-up was 49 (IQR 54) months, and there were no recurrences of leiomyoma. At the latest follow-up, the SF-36 scores were unchanged compared to baseline. However, there was a higher incidence of reflux symptoms (p < 0.050) and PPI use (p < 0.050) after endoscopic treatment.

Conclusions: Minimally invasive enucleation is safe and effective and can be performed by a variety of approaches according to leiomyoma location and morphology. Overall, health-related quality of life outcomes of each procedure appear satisfactory, but PPI dependence was greater in the endoscopic group.
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http://dx.doi.org/10.1007/s11605-019-04210-3DOI Listing
March 2020

Flexible versus rigid endoscopy in the management of esophageal foreign body impaction: systematic review and meta-analysis.

World J Emerg Surg 2018 12;13:42. Epub 2018 Sep 12.

Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Piazza E. Malan, 1, 20097 San Donato Milanese, Milan, Italy.

Background: Foreign body (FB) impaction accounts for 4% of emergency endoscopies in clinical practice. Flexible endoscopy (FE) is recommended as the first-line therapeutic option because it can be performed under sedation, is cost-effective, and is well tolerated. Rigid endoscopy (RE) under general anesthesia is less used but may be advantageous in some circumstances. The aim of the study was to compare the efficacy and safety of FE and RE in esophageal FB removal.

Methods: PubMed, MEDLINE, Embase, and Cochrane databases were consulted matching the terms "Rigid endoscopy AND Flexible endoscopy AND foreign bod*". Pooled effect measures were calculated using an inverse-variance weighted or Mantel-Haenszel in random effects meta-analysis. Heterogeneity was evaluated using index and Cochrane test.

Results: Five observational cohort studies, published between 1993 and 2015, matched the inclusion criteria. One thousand four hundred and two patients were included; FE was performed in 736 patients and RE in 666. Overall, 101 (7.2%) complications occurred. The most frequent complications were mucosal erosion (26.7%), mucosal edema (18.8%), and iatrogenic esophageal perforations (10.9%). Compared to FE, the estimated RE pooled success OR was 1.00 (95% CI 0.48-2.06;  = 1.00). The pooled OR of iatrogenic perforation, other complications, and overall complications were 2.87 (95% CI 0.96-8.61;  = 0.06), 1.09 (95% CI 0.38-3.18;  = 0.87), and 1.50 (95% CI 0.53-4.25;  = 0.44), respectively. There was no mortality.

Conclusions: FE and RE are equally safe and effective for the removal of esophageal FB. To provide a tailored or crossover approach, patients should be managed in multidisciplinary centers where expertise in RE is also available. Formal training and certification in RE should probably be re-evaluated.
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http://dx.doi.org/10.1186/s13017-018-0203-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6134522PMC
January 2019

Unusual foreign body impacted in the upper oesophagus: original technique for transoral extraction.

BMJ Case Rep 2018 Jun 27;2018. Epub 2018 Jun 27.

Department of Surgery, IRCCS Policlinico San Donato, Università degli Studi di Milano, Milano, Italy.

Foreign body ingestion is a common event; in the adult population, most ingestions occur in patients with mental disability, psychiatric disorders, alcohol intoxication or in prisoners seeking secondary gain. Removal through flexible endoscopy is generally the first-line approach but rescue oesophagotomy may be necessary for foreign bodies impacted in the upper oesophagus. A 27-year-old man was admitted in the emergency room after intentional ingestion of a wooden spherical object with a central hole. A total body CT scan showed that the object was completely obstructing the upper oesophageal lumen but there were no signs of perforation. In the operating room, a Weerda diverticuloscope and a 5 mm 0° telescope were used to visualise the foreign body under general anaesthesia. A standard endoscopic biopsy forceps was passed through the hole of the sphere and was retracted with the jaws open allowing transoral extraction without complications.
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http://dx.doi.org/10.1136/bcr-2018-225241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6020935PMC
June 2018

Impact of Laparoscopic Repair of Large Hiatus Hernia on Quality of Life: Observational Cohort Study.

Dig Surg 2019 20;36(5):402-408. Epub 2018 Jun 20.

Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milano, Italy,

Background: Laparoscopic surgery has proven safe and effective in the treatment of large hiatus hernia. Differences may exist between objectively assessed surgical outcomes, symptomatic scores, and patient-reported outcomes.

Methods: An observational, single-arm cohort study was conducted in patients undergoing primary laparoscopic repair with crura mesh augmentation and Toupet fundoplication for large (> 50% of intrathoracic stomach) type III-IV hiatus hernia. Data were extracted from hospital charts and a prospectively updated research database. The main study outcome was quality of life assessed by the Gastroesophageal reflux disease Health-Related Quality of Life (GERD-HRQL) score and the Short-form 36 (SF-36).

Results: Between 2013 and 2016, 37 out of 49 operated patients completed the comprehensive quality-of-life evaluation at the 2-year follow-up. The GERD-HRQL score significantly decreased compared to baseline (p < 0.001). All items of the SF-36 significantly improved compared to baseline (p < 0.05). Both Physical and Mental Component Summary scores were significantly higher than preoperative scores, with a medium Cohen's effect size (-0.77 and 0.56, respectively). At the 2-year follow-up, symptoms had disappeared in the majority of patients. The use of proton-pump inhibitors significantly decreased compared to baseline (13.5 vs. 86.4%, p < 0.001). Also, the use of antidepressants and benzodiazepines significantly decreased after surgery (8.1 vs. 32.4%, p < 0.001). The overall alimentary satisfaction score was > 8 in 92% of patients. There were no safety issues related to the use of the absorbable synthetic mesh. The incidence of anatomical hernia recurrence was 5.4%, but no patient with recurrent hernia required surgical revision.

Conclusions: Laparoscopic repair of large hiatus hernia with mesh and partial fundoplication is associated with symptomatic relief, no side-effects, and a significant improvement in disease-specific and generic quality of life at 2-year follow-up.
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http://dx.doi.org/10.1159/000490359DOI Listing
January 2020

Esophageal Resection for End-Stage Achalasia.

Am Surg 2018 Apr;84(4):506-511

Achalasia is a rare disease characterized by impaired lower esophageal sphincter relaxation loss and of peristalsis in the esophageal body. Endoscopic balloon dilation and laparoscopic surgical myotomy have been established as initial treatment modalities. Indications and outcomes of esophagectomy in the management of end-stage achalasia are less defined. A literature search was conducted to identify all reports on esophagectomy for end-stage achalasia between 1987 and 2017. MEDLINE, Embase, and Cochrane databases were consulted matching the terms "achalasia," "end-stage achalasia," "esophagectomy," and "esophageal resection." Seventeen articles met the inclusion criteria and 1422 patients were included in this narrative review. Most of the patients had previous multiple endoscopic and/or surgical treatments. Esophagectomy was performed through a transthoracic (74%) or a transhiatal (26%) approach. A thoracoscopic approach was used in a minority of patients and seemed to be safe and effective. In 95 per cent of patients, the stomach was used as an esophageal substitute. The mean postoperative morbidity rate was 27.1 per cent and the mortality rate 2.1 per cent. Symptom resolution was reported in 75 to 100 per cent of patients over a mean follow-up of 43 months. Only five series including 195 patients assessed the long-term follow-up (>5 years) after reconstruction with gastric or colon conduits, and the results seem similar. Esophagectomy for end-stage achalasia is safe and effective in tertiary referral centers. A thoracoscopic approach is a feasible and safe alternative to thoracotomy and may replace the transhiatal route in the future.
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April 2018

Factors affecting the caloric and protein intake over time in critically ill trauma patients.

J Surg Res 2018 06 10;226:64-71. Epub 2018 Feb 10.

Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, Los Angeles, California.

Background: Major trauma leads to increased nutritional requirements. However, little is known about the actual amount of calories and protein administered and the factors affecting the intake over time in critically ill trauma patients.

Methods: Prospective study including 100 trauma patients admitted to the Los Angeles County + University of Southern California Medical Center intensive care unit between March 2014 and October 2014. Inclusion criteria were age > 16 y, surgery at admission, and no oral nutrition. The caloric and protein intake was recorded, and requirements were calculated daily for 28 d. The nutritional intake and the impact of clinical factors on the intake over time were assessed using mixed model analysis.

Results: The caloric and protein intake significantly increased over time, but the median intake did not meet the median calculated requirements at any time. Multivariable analysis revealed a smaller increase of the nutritional intake over time in patients with an injury severity score > 45, whereas penetrating injury and laparotomy were associated with a higher increase of the intake. Body mass index scores ≥ 30 kg/m, traumatic brain injury, and gastrointestinal tract injuries were associated with a smaller increase of the caloric intake over time.

Conclusions: The median nutritional intake did not meet the median calculated requirements over time. A smaller increase of the nutritional intake over time was found in patients with a higher injury burden, whereas penetrating injury and laparotomy were associated with a higher increase of the intake. Higher body mass index scores, traumatic brain injury, and gastrointestinal tract injuries were associated with a smaller increase of the caloric intake over time. These clinical factors can help to adjust the nutritional support in critically ill trauma patients.
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http://dx.doi.org/10.1016/j.jss.2018.01.022DOI Listing
June 2018

Cricopharyngeal myotomy with thulium laser through flexible endoscopy: proof-of-concept study.

Endosc Int Open 2018 Apr 29;6(4):E470-E473. Epub 2018 Mar 29.

University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Milan, Italy.

Background And Study Aims : Endoscopic treatment of Zenker's diverticulum has proven feasible, but electrocautery and CO laser technology carry the risk of collateral thermal injury. Thulium laser septum incision may overcome this limitation. We describe for the first time the use of thulium laser through flexible endoscopy in a small cohort of patients with Zenker diverticulum.

Patients And Methods : Thulium laser septum division was performed via flexible endoscopy under general anesthesia in consecutive symptomatic patients with primary or recurrent Zenker diverticulum. Primary study outcomes were feasibility and safety of the procedure. A 1.9-μm laser fiber was used with an emission power of 10 - 16 W.

Results : Five patients were treated between May and June 2017. Two patients presented with recurrent symptomatic diverticulum after previous transoral septum stapling. Complete division of the septum was achieved in all patients. There was no bleeding nor need of adjunctive electrocautery devices to complete the procedure. The postoperative course was uneventful in all patients; the chest film and gastrographin swallow study on postoperative Day 1 were negative for pneumomediastinum, leaks or residual pouch. All patients were discharged within 48 hours on a soft diet. At the 1- and 3-month follow-up visits, all patients were satisfied with the procedure and reported improved swallowing and absence of regurgitation and cough.

Conclusions : Division of Zenker's septum with thulium laser is feasible and safe through flexible endoscopy. Longer-term follow-up is required to establish efficacy and effectiveness of this novel procedure.
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http://dx.doi.org/10.1055/a-0581-8789DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5880037PMC
April 2018

Early results of magnetic sphincter augmentation versus fundoplication for gastroesophageal reflux disease: Systematic review and meta-analysis.

Int J Surg 2018 Apr 20;52:82-88. Epub 2018 Feb 20.

University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy. Electronic address:

Background: Laparoscopic Nissen and Toupet fundoplication (LF) are currently considered gold-standard surgical treatment for Gastroesophageal Reflux Disease (GERD). Magnetic Sphincter Augmentation (MSA) is an innovative surgical procedure that has been showed to be effective to control GERD symptoms and to reduce esophageal acid exposure. The aim of this systematic review and meta-analysis was to compare early outcomes of LF and MSA.

Materials And Methods: PubMed, MEDLINE, Embase, and Cochrane databases were consulted matching the terms "Gastroesophageal reflux or heartburn", "LINX or magnetic sphincter augmentation" and "fundoplication". Pooled effect measures were calculated using an inverse-variance weighted or Mantel-Haenszel in random effects meta-analysis. Heterogeneity was evaluated using I-index and Cochrane Q-test. Meta-regression was used to address the effect of potential confounders.

Results: Seven observational cohort studies, published between 2014 and 2017, matched the inclusion criteria. Overall, 1211 patients, 686 MSA and 525 LF, were included. Postoperative morbidity ranged from 0 to 3% in the MSA group and from 0 to 7% in the LF group, and there was no mortality. Dysphagia requiring endoscopic dilatation occurred in 9.3% and 6.6% of patients respectively (OR = 1.56, 95% CI = 0.61-3.95, p = 0.119). The pooled OR of gas/bloat symptoms, ability to vomit, and ability to belch were 0.39 (95% CI 0.25-0.61; p < 0.001), 10.10 (95% CI 5.33-19.15; p < 0.001), and 5.53 (95% CI 3.73-8.19; p < 0.001), respectively. The postoperative GERD-HRQL was similar (p = 0.101). The pooled OR of PPI suspension, endoscopic dilation, and reoperation were similar in the two patients groups (p = 0.548, p = 0.119, p = 0.183, respectively).

Conclusion: Both anti-reflux procedures are safe and effective up to 1-year follow-up. PPI suspension rate, dysphagia requiring endoscopic dilatation, and disease-related quality of life are similar in the two patient groups. MSA is associated with less gas/bloat symptoms and increased ability to vomit and belch.
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http://dx.doi.org/10.1016/j.ijsu.2018.02.041DOI Listing
April 2018

Transanal removal of a broken drinking glass self-inserted and retained in the rectum.

BMJ Case Rep 2017 Jun 2;2017. Epub 2017 Jun 2.

Universita degli Studi di Milano, Biomedical Sciences for Health, Milano, Italy.

Retained rectal foreign bodies are increasingly reported in current clinical practice, and there is no clear consensus in the literature as to whether transanal extraction should be performed in the emergency or in the operating room. A 47-year-old presented to the hospital for a retained drinking glass in the rectum that was broken after an attempt at self-extraction. Physical examination showed no evidence of abdominal guarding nor bleeding from the rectum; abdominal and pelvic X-rays confirmed the presence of a broken glass, 8×6 cm in size and no signs of perforation. Initial anoscopy performed in the emergency room confirmed the partial fracture of the glass. The patient was transferred to the operating room and transanal extraction was carried out under general anaesthesia without complications.
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http://dx.doi.org/10.1136/bcr-2017-220268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5534995PMC
June 2017

Loss of muscle mass: a significant predictor of postoperative complications in acute diverticulitis.

J Surg Res 2017 05 9;211:39-44. Epub 2016 Dec 9.

Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California.

Background: Severe muscle mass depletion, sarcopenia, has been shown to be associated with poor operative outcomes. However, its impact on emergency abdominal operations remains unclear. The purpose of this study was to examine the association between low muscle mass (LMM) and outcomes after emergency operations for acute diverticulitis.

Patients And Methods: Patients ≥18 y requiring an emergency operation for acute diverticulitis between January 2007 and September 2014 were included. On preoperative computed tomography, the cross-sectional area (CSA) and transverse diameter (TVD) of the right and left psoas muscle were measured at the level of the third lumbar vertebral body. Sensitivity analysis was performed to determine appropriate CSA and TVD cutoff values defining low skeletal muscle mass. Clinical outcomes of patients with low muscle mass (LMM group) were compared with the non-LMM group.

Results: A total of 89 patients met our inclusion criteria. Median CSA and TVD were 794 mm and 24 mm, respectively. There was a strong correlation between the CSA and TVD (R = 0.84). In univariable analysis, significantly higher rates of postoperative major complications (63% versus 37%, P = 0.027) and surgical site infection (47% versus 19%, P = 0.008) were identified in the LMM group. After adjusting for clinically important covariates in a logistic regression model, patients with LMM were significantly associated with higher odds of major complications and surgical site infection.

Conclusions: Preoperative assessment of the psoas muscle CSA and TVD on computed tomography can be a practical method for identifying patients at risk for postoperative complications.
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http://dx.doi.org/10.1016/j.jss.2016.12.002DOI Listing
May 2017

Respiratory Symptoms and Complications of Zenker Diverticulum: Effect of Trans-Oral Septum Stapling.

J Gastrointest Surg 2017 Sep 3;21(9):1391-1395. Epub 2017 May 3.

Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy.

Background: Zenker diverticulum is a rare condition commonly associated with dysphagia and respiratory symptoms/complications, which are alarming especially in the elderly population. Aim of this study was to investigate the prevalence of respiratory symptoms/complications and the effects of minimally invasive trans-oral surgery in these patients.

Methods: Consecutive adult patients who underwent trans-oral septum stapling for Zenker diverticulum were included in a retrospective, observational cohort study. Pre- and postoperative symptoms, including chronic cough and aspiration pneumonia, were evaluated using a dedicated foregut questionnaire and were recorded on a prospectively maintained database. The operation was performed under general anesthesia. A barium swallow study and an upper gastrointestinal endoscopy were performed 6 months after the operation, and the foregut questionnaire was administered yearly.

Results: A total of 139 patients were finally included in the study. The median age was 72 years. In 62 (44.6%, CI 36.2-53.3) patients, there was a history of chronic cough and/or aspiration pneumonia. Chronic cough was associated with pneumonia (p < 0.001), while pneumonia was associated with severe regurgitation (p < 0.042) and weight loss (p = 0.001). The overall postoperative morbidity rate was 2.2% and there was no mortality. The median postoperative hospital stay was 2 days (range 0-22). The median follow-up was 38 months (range 2-105). At 3 years, a statistically significant reduction in the rate of chronic cough (36.8 vs. 7.9%, p < 0.001), recurrent episodes of pneumonia (6.6 vs. 0.0%, p = 0.031), dysphagia (78.9 vs. 6.6%, p < 0.001), and regurgitation (67.1 vs. 6.6%, p < 0.001) was recorded. The probability of remaining symptom-free at 90 months of follow-up was 0.818 (CI: 0.745-0.899).

Conclusions: Trans-oral septum stapling is safe and can effectively reduce the burden of respiratory symptoms and complications associated with Zenker diverticulum.
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http://dx.doi.org/10.1007/s11605-017-3435-9DOI Listing
September 2017

Short-Term Outcomes of Minimally Invasive Esophagectomy for Carcinoma In Patients with Liver Cirrhosis.

J Laparoendosc Adv Surg Tech A 2017 Jun 26;27(6):592-596. Epub 2017 Apr 26.

Division of General Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan , Milano, Italy .

Background: Open esophagectomy is a high-risk procedure in patients with liver cirrhosis. With the advent of minimally invasive surgical techniques, the overall morbidity and mortality rates of esophagectomy have decreased. The aim of this study was to describe short-term outcomes of minimally invasive esophagectomy in patients with proven liver cirrhosis.

Methods: Retrospective observational cohort study. Demographics, preoperative clinical characteristics, and outcomes of patients undergoing minimally invasive esophagectomy for carcinoma were analyzed. Patients with concomitant liver cirrhosis were compared to patients without liver cirrhosis undergoing similar surgical procedures. In addition, variables possibly associated with postoperative morbidity and mortality in patients with cirrhosis were investigated.

Results: Out of 443 patients undergoing minimally invasive esophagectomy, 18 (4.1%) had concomitant liver cirrhosis. Demographics and preoperative clinical variables were similar in the 2 patient groups. While the overall morbidity rate was similar, the 90-day mortality rate was significantly higher in patients with liver cirrhosis (P = .023). There was a significantly higher rate of sepsis and anastomotic, respiratory, and hemorrhagic complications in patients with liver cirrhosis who died in the postoperative period.

Conclusions: Minimally invasive esophagectomy is feasible in patients with liver cirrhosis. Future strategies should focus on total minimally invasive procedures and early recognition of surgical complications.
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http://dx.doi.org/10.1089/lap.2017.0115DOI Listing
June 2017

The seatbelt sign: early recognition may be life-saving.

BMJ Case Rep 2017 Apr 22;2017. Epub 2017 Apr 22.

Department of Surgery, IRCCS Policlinico San Donato, San Donato Milanese (Milano), Italy.

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http://dx.doi.org/10.1136/bcr-2017-219814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5534677PMC
April 2017

Isolated blunt pancreatic trauma: A benign injury?

J Trauma Acute Care Surg 2016 11;81(5):855-859

From the Division of Acute Care Surgery, Department of Surgery (S.S., E.W., E.B., K.I., D.D.), University of Southern California, Los Angeles, California.

Background: Blunt pancreatic trauma is rare, and the reported mortality is high. The true outcomes in isolated pancreas trauma are not known, and the optimal management according to injury severity is controversial. The present study evaluated the incidence, outcomes, and optimal management of isolated blunt pancreatic injuries.

Methods: National Trauma Data Bank study, including patients with blunt pancreatic trauma. Patients with major associated injuries or other severe intra-abdominal injuries were excluded. Patients' demographics, vital signs on admission, Abbreviated Injury Scale for each body area, Injury Severity Score (ISS), and therapeutic modality were extracted. Mortality and hospital length of stay were stratified according to the severity of pancreatic injury and therapeutic modality.

Results: There were 388,137 patients with blunt abdominal trauma. Overall, 12,112 patients (3.1%) sustained pancreatic injury. Isolated pancreatic injury occurred in 2,528 (0.7%) of all abdominal injuries or 20.9% of pancreatic injuries. Most injuries were low-grade Organ Injury Scale ((OIS) score of 2, 82.7%) with only a small percentage of higher-grade injuries (OIS score of 3, 7.9%; OIS score of 4, 3.9%; and OIS score of 5, 5.5%). Overall, most patients (74.1%) were managed nonoperatively. Nonoperative management was selected in 80.5% of pancreas OIS score of 2, 48.5% of OIS score of 3, and 40.9% of OIS scores of 4 to 5. The overall mortality rate was 2.4%, while in severe pancreatic trauma it was 3.0%. In minor pancreatic trauma, nonoperative management was associated with lower mortality and shorter hospital length of stay than operative management. However, in the group of patients with severe pancreatic trauma (OIS scores, 4-5) nonoperative management was associated with higher mortality and longer hospital stay than definitive operative management of the pancreas.

Conclusions: The mortality in isolated pancreatic trauma is low, even in severe injuries. Nonoperative management of minor pancreatic injuries is associated with lower mortality and shorter hospital stay than operative management. However, in severe trauma, nonoperative management is associated with higher mortality and longer hospital stay than operative management.

Level Of Evidence: Prognostic study, level III; therapeutic study, level IV.
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http://dx.doi.org/10.1097/TA.0000000000001224DOI Listing
November 2016

Prehospital intubation for isolated severe blunt traumatic brain injury: worse outcomes and higher mortality.

Eur J Trauma Emerg Surg 2017 Dec 27;43(6):731-739. Epub 2016 Aug 27.

Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles County and University of Southern California Medical Center, 1200 N. State St, Inpatient Tower (C)-Rm C5L100, Los Angeles, CA, 90033, USA.

Purpose: Prehospital endotracheal intubation (ETI) for traumatic brain injury (TBI) is a controversial issue. The aim of this study was to investigate the effect of prehospital ETI in patients with TBI.

Methods: Cohort-matched study using the US National Trauma Data Bank (NTDB) 2008-2012. Patients with isolated severe blunt TBI (AIS head ≥3, AIS chest/abdomen <3) and a field GCS ≤8 were extracted from NTDB. A 1:1 matching of patients with and without prehospital ETI was performed. Matching criteria were sex, age, exact field GCS, exact AIS head, field hypotension, field cardiac arrest, and the brain injury type (according PREDOT-code). The matched cohorts were compared with univariable and multivariable regression analysis.

Results: A total of 27,714 patients were included. Matching resulted in 8139 cases with and 8139 cases without prehospital ETI. Prehospital ETI was associated with significantly longer scene (median 9 vs. 8 min, p < 0.001) and transport times (median 26 vs. 19 min, p < 0.001), lower Emergency Department (ED) GCS scores (in patients without sedation; mean 3.7 vs. 3.9, p = 0.026), more ventilator days (mean 7.3 vs. 6.9, p = 0.006), longer ICU (median 6.0 vs. 5.0 days, p < 0.001) and total hospital length of stay (median 10.0 vs. 9.0 days, p < 0.001), and higher in-hospital mortality (31.4 vs. 27.5 %, p < 0.001). In regression analysis prehospital ETI was independently associated with lower ED GCS scores (RC -4.213, CI -4.562/-3.864, p < 0.001) and higher in-hospital mortality (OR 1.399, CI 1.205/1.624, p < 0.001).

Conclusion: In this large cohort-matched analysis, prehospital ETI in patients with isolated severe blunt TBI was independently associated with lower ED GCS scores and higher mortality.
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http://dx.doi.org/10.1007/s00068-016-0718-xDOI Listing
December 2017