Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Spontaneous ruptured pheochromocytoma: a case report

We present a rare case of intra-abdominal hemorrhage due to a ruptured pheochromocytoma. Our patient presented with signs of shock. By emergency surgery, an hemorrhagic pheochromocytoma of the left adrenal gland was removed. The recover was uneventful. In cases of suspected hemorrhagic pheochromocytoma with severe shock, prompt surgery is mandatory and catecholamines administration may be crucial to resolve hypotension and guarantee an uneventful recover

Infezioni opportuniste gastrointestinali e HIV. Caso clinico

Gli ultimi dati della letteratura parlano di milioni di persone affette da AIDS nel mondo. Negli ultimi 5 anni il tasso di mortalità si è ridotto dal 20% al 15%; tuttavia circa 75000 pazienti moriranno di AIDS nell’anno in corso. I pazienti affetti da immunodeficienza acquisita da virus HIV sono a rischio di sviluppare neoplasie AIDS-correlate, come il sarcoma di Kaposi e i linfomi non Hodgkin, neoplasie sporadiche e infezioni secondarie. Tra queste le infezioni da Cytomegalovirus (CMV) sono spesso causa di corioretinite, polmoniti, ulcere perineali, esofagiti, lesioni renali e del sistema nervoso centrale. Descritta, ma non di frequente riscontro, la comparsa di sindromi addominali acute che talvolta necessitano di trattamento chirurgico d’urgenza. Le lesioni intestinali da sovrainfezione cytomegalica sono abbastanza frequenti (15-43%), riguardano per il 47% il colon, per il 21,7% il duodeno, per il 17,4% lo stomaco e per il 4,3% il piccolo intestino ma solo raramente sono a prognosi infausta. Gli Autori riportano il raro caso clinico di un paziente positivo per HIV, giunto alla loro osservazione con associata micobatteriosi e infezione multiorgano da CMV, sottoposto ad intervento chirurgico d’urgenza per perforazioni intestinali multipl

Pre-surgery dietician counseling can prevent post-thyroidectomy body weight gain: results of an intervention trial

Purpose: It is widely accepted that patients experience weight gain after total thyroidectomy, and preventive measures should be recommended. Methods: A prospective study was designed to assess the efficacy of a dietetic intervention to prevent post-thyroidectomy weight gain in patients undergoing surgery for both benign and malignant thyroid conditions. Patients undergoing total thyroidectomy were prospectively and randomly assigned to receive a personalized pre-surgery diet counseling (GROUP A) or no intervention (GROUP B), according to a 1:2 ratio. All patients underwent follow-up with body-weight measurement, thyroid function evaluation and lifestyle and eating habits assessment at baseline (T0), 45 days (T1) and 12 months (T2) post-surgery. Results: The final study group encompassed 30 patients in Group A and 58 patients in Group B. The two groups were similar in terms of age, sex, pre-surgery BMI, thyroid function and underlying thyroid condition. The evaluation of body weight variations showed that patients in Group A did not experience significant body weight changes at either T1 (p = 0.127) nor T2 (p = 0.890). At difference, patients in Group B underwent a significant body weight increase from T0 to both T1 (p = 0.009) and T2 (p = 0.009). TSH levels were similar in the two groups, both at T1 and T2. Lifestyle and eating habits questionnaires failed to register any significant difference between the two groups, apart from an increase in sweetened beverages consumption in Group B. Conclusions: A dietician counseling is effective in preventing the post-thyroidectomy weight gain. Further studies in larger series of patients with a longer follow-up appear worthwhile

Enterorragia massiva da diverticolosi sigmoidea in corso di terapia antiaggregante. Caso clinico

Di frequente riscontro nei Paesi Occidentali, la malattia diverticolare nel 5% dei casi può essere causa di grave sanguinamento, instabilità emodinamica e rischio di vita per il paziente. Gli Autori riportano il caso di una paziente di 74 anni giunta alla loro osservazione con segni e sintomi da grave enterorragia. La paziente era in trattamento antiaggregante con acido acetilsalicilico clopidogrel per la prevenzione della restenosi dopo posizionamento di stent coronarici automedicati per sindrome coronarica acuta. Assumeva contemporaneamente rosuvastatina per il controllo della ipercolesterolemia primaria. La gravità del sanguinamento ha richiesto la stabilizzazione emodinamica mediante infusione di colloidi e sangue intero. Le emorragie iterative, in numero di sette, hanno consigliato l’esecuzione di un’arteriografia selettiva che ha dimostrato un sanguinamento nel territorio di distribuzione delle arterie sigmoidee e dell’arteria rettale superiore. Nel corso della metodica interventistica si è proceduto ad embolizzazione del tronco comune dell’arteria mesenterica inferiore con spirale metallica tipo BALT, seguita da arresto dell’emorragia. La rettosigmoidocolonscopia eseguita a distanza di 15 giorni dalla procedura embolizzante ha dimostrato la presenza di malattia diverticolare del sigma. Sicuramente la terapia con acido acetilsalicilico e clopidogrel ha contribuito in maniera determinante alla gravità dell’episodio emorragico che ha messo a rischio di vita la paziente. Alla luce di recenti evidenze sperimentali e cliniche è inoltre ipotizzabile un ruolo delle statine nel favorireil sanguinamento mediante un effetto ipoaggregante piastrinico

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Background: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19\ub78 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6\ub76 and 2\ub74 per cent respectively before, but 23\ub77 and 5\ub73 per cent, during the pandemic (both P < 0\ub7001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2