[Priorities in the treatment of the multiply injured. The experience of the Piedmont Trauma Center].
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Biomedical subjects
Publications and source records attributed to F Ibba.
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Seventeen cases of segmental portal hypertension due to splenic vein thrombosis are reported. This syndrome may be asymptomatic for a long time and then present suddenly in the form of a serious picture of high digestive haemorrhage due to rupture of gastric fundus varices as a result of hypertrophied submucous collateral drainage circulation. Useful for diagnosis are oesophagogastroduodenoscopy, which points to stomach varices, and splenoportography or splenic artery angiography with venous phase, which highlight pathognomonic dilatation and tortuosity of the gastroepiploic veins. Surgical exploration typically shows: presence of large epiploic vessels, splenomegaly, absence of changes in the liver and in the portal and mesenteric circulation. Curative treatment of choice is splenectomy.
Two cases of intramural haematoma of the duodenum caused by injury are examined. The clinical signs were non-specific: vomiting and epigastric pain. The salient features of laboratory tests were leucocytosis and hyperamylasaemia. Radiography of the digestive tract revealed classic bunching of the mucous plicae in the second section of the duodenum in one case and a mark on the gastric antrum together with a clear stretch in the third duodenal section in the other. Surgical examination and drainage of the haematoma was performed in one case while the other was given conservative treatment. Both patients were clinically cured on release from hospital.
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An examination is made of a series of emergency operations carried out in the period 1974-78 to arrest haemorrhage due to the rupture of oesophageal varices. An account is given of the personal criteria employed in the choice of candidates and the type of surgical management. Stress is laid on the need for greater aggressivity. In addition, support is expressed for the porto-systemic shunts, especially shunts of the porto-cava and meso-cava type. These are superior to other forms on account of their easy and rapid execution.
The technique used to carry out pancreaticogastrostomy after duodenocephalopancreatectomy in 4 cases is described. The technique is better than pancreaticojejunostomy, which is associated with a high incidence of postoperative complications, such as abscesses, fistulae, haemorrhage, and autodigestion at the site of anastomosis.
Six cases of delayed rupture of the spleen in two stages are described. One case of occult rupture is also presented. A picture of acute anaemia was observed in the five two-stage cases, whereas the occult rupture was diagnosed as organised splenic haematoma following computerised scintiscanning, arteriography and tomography. Splenectomy was performed in all cases, under emergency conditions in the first five, and of choice in the sixth. No post-operative complications were noted.
Three typical cases of segmental portal hypertension due to occlusion of the splenic vein are reported. This syndrome may be asymptomatic for a very long time and then present suddenly in the form of a serious picture of high digestive haemorrhage due to rupture of the varices of the fundus of the stomach as a result of hypertrophized submucous collateral drainage circulation. Useful for diagnosis are oesophagogastroduodenoscopy, which points to stomach varices, and splenoportography or superselective arteriography of the splenic artery with venous phase, which highlight pathognomonic dilatation and tortuosity of the gastroepiploic veins. Surgical exploration typically shows: presence of large epipolic vessels, splenomegaly, absence of changes in the liver and in the portal and mesenteric circulation. Resolutive treatment of choice is splenectomy.
Oesophagogastroplasty has been performed in 4 patients in the Turin Department of Emergency Surgery. Three of them presented high neoplastic lesion of the oesophagus, while the fourth was suffering from mediastinic compression due to sclerosing mediastinitis. The technique and results are reported in detail. Indications for surgery for both malignant and benign lesions are presented. The real advantages of the operation with respect to stomach to chest transposition and oesophagocolonplasty which have in the personal series created considerable inconvenience, are discussed. The reasons making it necessary to carry out the operation in two stages, with different modalities, are also discussed. Complications are indicated and postoperative treatment discussed. This plays a notable part in the success of the operation, as does correct technique.
A series of patients with acute renal failure (ARF) and acute abdomen collected by the St. John the Baptist Hospital's Nephrology and Dialysis Division over the period 1970-75 is examined. A high rate of mortality was noted, due to causes that were mostly independent of ARF Death was often related to failure to resolve acute abdomen. The progression of ARF appeared to be related to that of the abdominal affection with prompt resolution of the latter. These findings suggest that constriction of the afferent arteriole may offer a partial, functional basis for ARF with the corollary that it has a good chance of being reversed, even after protracted periods of anuria. Renal complications associated with disseminated or localised intravascular coagulation appear to be rare. Treatment was best directed to early and frequent dialysis, with surgical resolution whenever indicated, irrespective of the presence of ARF.
9 cases of caustic ingestion are reported and the diagnostic and therapeutic problems of the consequent gastritis and oesophagitis conditions discussed. In the case of small quantities of acids at low concentrations, the immediate steps are largely medical and conservative, their purpose being to monitor complications. In cases of massive ingestion, surgery should be as early as possible to avoid secondary lesions to the surrounding viscera and serious electrolytic imbalances; the limit for action with a relatively favourable prognosis is within 5 hours and removal of the damaged segments must be radical and extensive.
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Reference is made to the literature data and a personal series for the proposal of ligation of hepatic artery as a useful means of controlling: 1) massive haemorrhage following certain forms of liver trauma; 2) haemorrhage following lobectomy or atypical subtotal resection; 3) post-traumatic haemobilia. It is a valuable alternative to lobar resection which, in spite of its over 50% mortality, is still the treatment of choice in serious lesions, especially if these are associated with lesions of the suprahepatic veins or cava, or massive crushing of the parenchima. Haemorrhagic shock following liver damage is usually met by reduced portal and increased hepatic artery flow. It is obvious that ligation of the hepatic artery leads to considerable ischaemia and hypoxia. This disadvantage can only be offset by massive replacement transfusions, protracted parenteral feeding (fasting leads to maximum oxygenation of the portal blood), and intravenous glucagone, to improve the overall liver blood flow and the oxygen saturation of the portal blood.
Rodney-Smith's technique (transtumoral transhepatic drainage) was used palliatively in 6 patients with cancer of the upper biliary tracts. Diagnosis from the symptomatology (essentially obstructive icterus) was not easy, though the picture can almost always be clarified by endovenous and endoscopic retrograde cholangiography and, more particularly, by preoperative and intrahepatic intraoperative cholangiography and choledochoscopy in connection with laparatomy. Two patients survived for 9 months and 2 yr respectively, whereas the remainder died within 30 days of surgery. Despite this high mortality, primarily due to very poor general condition, this type of palliative operation is still the best form of management.
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