Metabolic Syndrome (MetS), Systemic Inflammatory Response Syndrome (SIRS), and Frailty: Is There any Room for Good Outcome in the Elderly Undergoing Emergency Surgery?

Background: Patients with MetS or SIRS experience higher rates of mortality and morbidity, across both cardiac and noncardiac surgery. Frailty assessment has acquired increasing importance in recent years as it predisposes elderly patients to a worse outcome. The aim of our study was to investigate the influence of MetS, SIRS, and with or without frailty on elderly patients undergoing emergency surgical procedures. Methods: We analyzed data of all patients with nonmalignant diseases requiring an emergency surgical procedure from January 2017 to December 2020. The occurrence of MetS was identified using modified definition criteria used by the NCEP-ATP III Expert Panel: obesity, hypertension, diabetes, or if medication for high triglycerides or for low HDL cholesterol was taken. Systemic inflammatory response syndrome (SIRS) was evaluated according to the original consensus study (Sepsis-1). The frailty profile was investigated by the 5-modified Frailty Index (5-mFI) and the Emergency Surgery Frailty Index (EmSFI). Postoperative complications have been reported and categorized according to the Clavien–Dindo (C–D) classification system. Morbidity and mortality have been mainly considered as the 30-day standard period definition. Results: Of the 2,318 patients included in this study, 1,010 (43.6%) fulfilled the criteria for MetS (MetsG group). Both 5-Items score and EmsFI showed greater fragility in patients with MetS. All patients with MetS showed more frequently a CACI index greater than 6. The occurrence of SIRS was higher in MetSG. LOS was longer in patients with MetS (MetSG 11.4 ± 12 days vs. n-MetSG 10.5 ± 10.2 days, p = 0.046). MetSG has a significantly higher rate of morbidity (353 (35.%) vs. 385 (29.4%), p = 0.005). The mortality rate in patients with MetS (98/1010, 10%) was similar to that in patients without it (129/1308, 10%). Considering patients with MetS who developed SIRS and those who had frailty or both, the occurrence of these conditions was associated with a higher rate of morbidity and mortality. Conclusion: Impact of MetS and SIRS on elderly surgical patient outcomes has yet to be fully elucidated. The present study showed a 43.6% incidence of MetS in the elderly population. In conclusion, age per se should be not considered anymore as the main variable to estimate patient outcomes, while MetS and Frailty should have always a pivotal role

Perforated peptic ulcer (PPU) treatment: an Italian nationwide propensity score-matched cohort study investigating laparoscopic vs open approach

BackgroundPerforated peptic ulcer (PPU) remain a surgical emergency accounting for 37% of all peptic ulcer-related deaths. Surgery remains the standard of care. The benefits of laparoscopic approach have been well-established even in the elderly. However, because of inconsistent results with specific regard to some technical aspects of such technique surgeons questioned the adoption of laparoscopic approach. This leads to choose the type of approach based on personal experience. The aim of our study was to critically appraise the use of the laparoscopic approach in PPU treatment comparing it with open procedure.MethodsA retrospective study with propensity score matching analysis of patients underwent surgical procedure for PPU was performed. Patients undergoing PPU repair were divided into: Laparoscopic approach (LapA) and Open approach (OpenA) groups and clinical-pathological features of patients in the both groups were compared.ResultsA total of 453 patients underwent PPU simple repair. Among these, a LapA was adopted in 49% (222/453 patients). After propensity score matching, 172 patients were included in each group (the LapA and the OpenA). Analysis demonstrated increased operative times in the OpenA [OpenA: 96.4 +/- 37.2 vs LapA 88.47 +/- 33 min, p = 0.035], with shorter overall length of stay in the LapA group [OpenA 13 +/- 12 vs LapA 10.3 +/- 11.4 days p = 0.038]. There was no statistically significant difference in mortality [OpenA 26 (15.1%) vs LapA 18 (10.5%), p = 0.258]. Focusing on morbidity, the overall rate of 30-day postoperative morbidity was significantly lower in the LapA group [OpenA 67 patients (39.0%) vs LapA 37 patients (21.5%) p = 0.002]. When stratified using the Clavien-Dindo classification, the severity of postoperative complications was statistically different only for C-D 1-2.ConclusionsBased on the present study, we can support that laparoscopic suturing of perforated peptic ulcers, apart from being a safe technique, could provide significant advantages in terms of postoperative complications and hospital stay

Gastro-intestinal emergency surgery: Evaluation of morbidity and mortality. Protocol of a prospective, multicenter study in Italy for evaluating the burden of abdominal emergency surgery in different age groups. (The GESEMM study)

Gastrointestinal emergencies (GE) are frequently encountered in emergency department (ED), and patients can present with wide-ranging symptoms. more than 3 million patients admitted to US hospitals each year for EGS diagnoses, more than the sum of all new cancer diagnoses. In addition to the complexity of the urgent surgical patient (often suffering from multiple co-morbidities), there is the unpredictability and the severity of the event. In the light of this, these patients need a rapid decision-making process that allows a correct diagnosis and an adequate and timely treatment. The primary endpoint of this Italian nationwide study is to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18. Secondary endpoints will be to evaluate to analyze the prognostic role of existing risk-scores to define the most suitable scoring system for gastro-intestinal surgical emergency. The primary outcomes are 30-day overall postoperative morbidity and mortality rates. Secondary outcomes are 30-day postoperative morbidity and mortality rates, stratified for each procedure or cause of intervention, length of hospital stay, admission and length of stay in ICU, and place of discharge (home or rehabilitation or care facility). In conclusion, to improve the level of care that should be reserved for these patients, we aim to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18, to analyze the prognostic role of existing risk-scores and to define new tools suitable for EGS. This process could ameliorate outcomes and avoid futile treatments. These results may potentially influence the survival of many high-risk EGS procedure

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine

[This corrects the article DOI: 10.1186/s13054-016-1208-6.]

Lower Limbs Venous Kinetics and Consequent Impact on Drainage Direction

Objective There is still a lack of literature concerning lower extremity venous hemodynamics. The interpretation of physiological order of venous emptying indicates the direction of drainage is from the most superficial to the deepest veins. Nevertheless, there is no evidence concerning the different venous systems kinetics: the deep venous network (N1), the saphenous system (N2), the tributaries network (N3). Aim of the present study is to assess these velocities and to find clues for a physical model identification. Methods Venous Doppler investigations were performed in 18 healthy subjects (mean age 25 + 5 yo, M/F 1/1) for a total of 36 lower limbs. Diameters, peak systolic velocity (PSV) and time average velocity (TAV) of the following were assessed: N1 external iliac vein (IL), common femoral vein (CFV) above the sapheno-femoral junction (SFJ), middle thigh femoral vein (MFV), popliteal vein (PV), posterior tibial vein (PTV). N2 great saphenous vein (GSV) at the SFJ, midthigh GSV (MTGSV), midleg GSV (MLGSV), small saphenous vein (SSV) at its confluence with the popliteal vein (SPJ), midleg (SSV). N3 (whatever flow detectable GSV and/or SSV tributary). The flow was elicited both by active foot dorsiflexion, (AFD) and passive manual compression/relaxation, (C/R) maneuvers. Results The detailed values have been reported in table 1. A TAV increase was demonstrated from the most superficial N3 to the progressively deeper N2 and N1 compartments (P < .0001). Inside the single compartments no statistical differences were reported among the different segments. TAV and PSV showed a direct correlation with TAV following C/R (r2 = 0.91; P < .0001) and AFD (r2=0.95; P < .0001). The comparison among TAV following C/R and AFD showed no statistically significant differences (P = NS), except in IL (P < .0005) and in N3 (P < .0005). A diameter decrease was reported from N1 to N3 (P < .0001). A direct correlation has been found among diameter and TAV both by C/R (r2 = 0,8; P < .0005) and AFD (r2 = 0.9; P < .0001). Conclusions The present investigation provides preliminary evidences of the velocity decrease from the deepest to the most superficial compartments. These data introduce the Venturi effect as potential factor in the flow aspiration from the tributary to the deeper veins. This work is to be considered preliminary. Nevertheless the reported data represent a first step toward an objective evaluation of the hemodynamics governing the lower limb drainage. Moreover, these values can constitute the basis for further investigations in pathological and post-procedural scenarios. Table. Venous networks velocities and diameters N1 N2 N3 IL CVF MCFV PV PTV SFJ MTGSV MLGSV SSV TRIBUTARY PSVC/R cm/sec 111.2 ± 46.2 111.2 ± 26.3 112.8 ± 36.9 85.5 ± 32.3 46.8 ± 24.5 36.9 ± 26.2 49.29 ± 32.5 39.7 ± 14.3 19.8 ± 7.7 11.0 ± 3.8 PSVAFD cm/sec 111.5 ± 37.2 103.9 ± 35.5 83.3 ± 27.6 83.6 ± 28.9 48.1 ± 24.1 32.0 ± 15.8 35.1 ± 23.9 29.3 ± 12.2 25.5 ± 11.2 19.2 ± 13.0 TAVC/R cm/sec 39.6 ± 16.6 41.8 ± 11.2 43.2 ± 15.0 40.1 ± 21.6 29.4 ± 19.4 18.1 ± 12.3 21.6 ± 17.4 16.8 ± 5.0 10.8 ± 3.1 5.1 ± 2.12 TAVAFD cm/sec 41.4 ± 20.8 38.9 ± 14.6 37.2 ± 21.0 30.4 ± 10.7 25.6 ± 16.7 15.2 ± 8.8 18.9 ± 8.5 14.5 ± 7.8 14.4 ± 7.2 10.7 ± 7.8 DIAM mm 13.9 ± 2.7 12.4 ± 2.8 9.7 ± 2.5 8.5 ± 2.3 4.2 ± 0.7 3.75 ± 0.8 2.78 ± 0.7 2.32 ± 0.3 2.7 ± 0.61 1.1 ± 0.3 Table options Author Disclosures: S. Gianesini: Nothing to disclose; F. Sisini: Nothing to disclose; G. di Domenico: Nothing to disclose; E. Menegatti: Nothing to disclose; M. Vannini: Nothing to disclose; P. Spath: Nothing to disclose; P. Dalla Caneva: Nothing to disclose; S. Occhionorelli: Nothing to disclose; M. Tessari: Nothing to disclose; M. Gambaccini: Nothing to disclose; P. Zamboni: Nothing to disclose

Appendectomy versus conservative treatment with antibiotics for patients with uncomplicated acute appendicitis: a propensity score–matched analysis of patient-centered outcomes (the ACTUAA prospective multicenter trial)

Purpose: The aim of this prospective multicenter study was to compare antibiotic therapy and appendectomy as treatment for patients with uncomplicated appendicitis confirmed by ultrasound and/or computed tomography. Methods: The study was conducted from January 2017 to January 2018. Data regarding all patients discharged from the participating centers with a diagnosis of uncomplicated appendicitis were collected prospectively. Results: Of the 318 patients enrolled in the study, 27.4% underwent antibiotic-first therapy, and 72.6% underwent appendectomy. The matched group was composed of 87 patients in both study arms. Of the 87 patients available of 1-year follow-up in the antibiotic-first group, 64 (73.6%) did not require appendectomy. The complication-free treatment success in the antibiotic-first group was 64.4%. A statistically significant higher complication-free treatment success was found in the appendectomy group: 81.8% in the pre-matching sample and 83.9% in the post-matching sample. Patients in the antibiotic-first group reported lower VAS scores compared to those treated with an appendectomy, both at discharge (2.0 ± 1.7 vs 3.6 ± 2.3) and at 30-day follow-up (0.3 ± 0.6 vs 2.1 ± 1.7). The mean of the days of absence from work was higher in the appendectomy group (β 0.63; 95% CI 0.08–1.18). Conclusion: Although laparoscopic appendectomy remains the gold standard of treatment for uncomplicated appendicitis, conservative treatment with antibiotics is a safe option in most cases. Approximately 65% of patients treated with antibiotics are symptom-free at 1&nbsp;year, without increased risk of adverse events should symptoms recur, and better outcomes in terms of less pain and shorter period of absence from work compared to patients undergoing an appendectomy. Trial registration: Clinicaltrials.gov identifier (NCT number): NCT03080103

Correction to: Appendectomy versus conservative treatment with antibiotics for patients with uncomplicated acute appendicitis: a propensity score–matched analysis of patient-centered outcomes (the ACTUAA prospective multicenter trial) (International Journal of Colorectal Disease, (2021), 36, 3, (589-598), 10.1007/s00384-021-03843-8)

All authors and affiliations of the The ACTUAA Study Collaborative Working Group are listed in the Acknowledgments section of the original published version of this article however, Luca Gordini and Silvia Sanna should have been added in the list. Thus, the names are now presented and cited correctly. The original article has been corrected

Risk factors for postoperative morbidity following appendectomy in the elderly: a nationwide prospective cohort study

Background: A limited number of studies investigating perioperative risk factors associated with emergency appendectomy in elderly patients have been published to date. Whether older age may be associated with poorer outcomes following appendectomy is still a matter of debate. The primary aim of this study was to determine the predictors of postoperative morbidity following appendectomy in patients aged ≥ 65&nbsp;years. Methods: Data regarding all elderly patients who underwent emergency appendectomy from January 2017 to June 2018 admitted 36 Italian surgical departments were prospectively collected and analyzed. Baseline demographics and perioperative variables were evaluated. Uni- and multivariate analyses adjusted for differences between groups were carried out to determine possible predictors of adverse outcomes after appendectomy. Results: Between January 2017 and June 2018, 135 patients aged ≥ 65&nbsp;years with a diagnosis of AA met the study inclusion criteria. Twenty-six patients (19.3%) were diagnosed with some type of postoperative complication. Decreasing the preoperative hemoglobin level showed a statistically significant association with postoperative complications (OR 0.77, CI 0.61–0.97, P = 0.03). Preoperative creatinine level (P = 0.02, OR 2.04, CI 1.12–3.72), and open appendectomy (P = 0.03, OR 2.67, CI 1.11–6.38) were significantly associated with postoperative morbidity. After adjustment, the only independent predictor of postoperative morbidity was preoperative creatinine level (P = 0.04, OR 2.01, CI 1.05–3.89). Conclusions: In elderly patients with AA, perioperative risk assessment in the emergency setting must be as accurate as possible to identify modifiable risk factors that can be addressed before surgery, such as preoperative hemoglobin and creatinine levels

Interobserver reproducibility of immunohistochemical HER-2/neu assessment in human breast cancer: An update from INQAT round III

The clinical interest in HER-2/neu is related to trastuzumab, a drug used to treat patients with invasive breast carcinoma overexpressing the HER-2/neu protein. It is very important to correctly identify those patients who may benefit from trastuzumab by accurate assessment of the HER-2/neu status. Of the various methods available, the Dako Herceptest for immunolhistochemical assay is considered the most reliable to reach this goal. The aim of this study was to investigate within a group of Italian laboratories the reproducibility of the results of HER-2/neu assessment by means of the Dako scoring system on slides stained with the Herceptest kit. This study was also conceived as the continuation of one of our previous studies, which was similar in its aims but different in the classification criteria adopted. Our results show that, whereas the intra-observer reproducibility was generally satisfactory, the interobserver reproducibility was not. Moreover, our findings confirm that the two extreme classes (0 and 3+) are more easy to identify than the other two and that the Herceptest does not allow to discriminate optimally between scoring classes 2+ and 3+. These findings are relevant in clinical practice where the treatment choice is based on categories defined by this assay, suggesting the need of adopting educational programs and/or new reference materials to improve the assay performance

Risk factors for postoperative morbidity following appendectomy in the elderly: a nationwide prospective cohort study

Background: A limited number of studies investigating perioperative risk factors associated with emergency appendectomy in elderly patients have been published to date. Whether older age may be associated with poorer outcomes following appendectomy is still a matter of debate. The primary aim of this study was to determine the predictors of postoperative morbidity following appendectomy in patients aged ≥ 65&nbsp;years. Methods: Data regarding all elderly patients who underwent emergency appendectomy from January 2017 to June 2018 admitted 36 Italian surgical departments were prospectively collected and analyzed. Baseline demographics and perioperative variables were evaluated. Uni- and multivariate analyses adjusted for differences between groups were carried out to determine possible predictors of adverse outcomes after appendectomy. Results: Between January 2017 and June 2018, 135 patients aged ≥ 65&nbsp;years with a diagnosis of AA met the study inclusion criteria. Twenty-six patients (19.3%) were diagnosed with some type of postoperative complication. Decreasing the preoperative hemoglobin level showed a statistically significant association with postoperative complications (OR 0.77, CI 0.61–0.97, P = 0.03). Preoperative creatinine level (P = 0.02, OR 2.04, CI 1.12–3.72), and open appendectomy (P = 0.03, OR 2.67, CI 1.11–6.38) were significantly associated with postoperative morbidity. After adjustment, the only independent predictor of postoperative morbidity was preoperative creatinine level (P = 0.04, OR 2.01, CI 1.05–3.89). Conclusions: In elderly patients with AA, perioperative risk assessment in the emergency setting must be as accurate as possible to identify modifiable risk factors that can be addressed before surgery, such as preoperative hemoglobin and creatinine levels