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)

Small bowel obstruction due to metastasis of cutaneous melanoma: 7-years after primary diagnosis.

Aim of study: Metastatic involvement of the small bowel by melanoma is rare. The average time from the excision of the primary cutaneous melanoma to the occurrence of intestinal metastases tends to be between 3 and 5 years; one case of recurrence after 15 years is described. The most common kind of lesion is polypoid: this can cause intussusception and intestinal occlusion. We report a case of intestinal occlusion by an ileal metastasis of a melanoma occurred 7 years earlier. Materials and Methods: Case Report: The patient was a 57-year-old female who was admitted to our hospital for persistent abdominal pain and sub-occlusion. The patient's past medical history included cutaneous malignant melanoma 7 years before and lobular breast adenocarcinoma 10 years before. During the previous three months, she had intermittent abdominal pain and a weight loss of about 7 kg. Abdominal-US, EGDS and colonoscopy were all negative for pathologic findings. During the hospital stay, a CT enterography revealed lower intestinal intussusception, and enlarged lymph nodes both in the abdominal cavity and in the retroperitoneum. Intraoperatively we found an ileal invagination due to a polypoid mass of the ileal tract. Segmental ileal resection was performed; wide mesenteric lymph node dissection was not possible because of large and extended retroperitoneal lymphadenopathies. Histological examination showed epithelioid and spindle tumor cells with obvious cytoplasmic melanin deposition. Immunohistochemical staining revealed that tumor cells were positive for S-100, HMB-45 and vimentin, confirming the diagnosis of melanoma. Main results and conclusions: Appearance of GI metastases is reported up to 15 years after the inital diagnosis of melanoma. Reported clinical signs and symptoms generally include chronic abdominal pain, occult or gross bleeding and, as in this case, weight loss. Aspecificity of symptoms may impede early diagnosis and treatment of the disease. As in this case, where curative surgery is impossible because of the extent of disease, metastatic tumor resection or GI tract bypass surgery is recommended to relieve symptoms or avoid future complications. Early diagnosis of metastases requires adequate imaging (CT) and prolonged follow up

FACTORS PREDICTING MORBIDITY AND MORTALITY AFTER SURGERY FOR COMPLICATED ACUTE DIVERTICULITIS: A SINGLE CENTER EXPERIENCE

Introduzione Complicated acute diverticulitis (CAD) occurs in approximately 10 to 25 percent of patients affected by diverticular disease and a surgical treatment is often necessary. Postoperative morbidity and mortality are still high, up to 40% of cases in patients with generalized peritonitis. The purpose of this study is to identify predictive prognostc factor for postoperative morbidity and mortality in patients requiring surgical intervention for CAD. Pazienti e metodi From September 2011 to May 2015 170 patients underwent surgical intervention for diverticular disease in our unit. Of these, 119 patients required urgent surgery for complicated acute diverticulitis (CAD). Pre-, intra- and postoperative findings were collected in a prospective database. Multivariate analysis with logistic regression was performed to find out independent predictive factors for postoperative morbidity and mortality. Statistical analysis was made with SPSS v.13.0 and significance was considered with p value < 0.05. Risultati There were 56 males and 63 females with mean age of 68 \ub1 15 years. 100 patients (84.0%) were at first hospital admission for diverticular disease and in 16 cases (13.4%) the disease was localized at right colon or ceacum. A stomy was required in 84 patients (70.6%) and postoperative morbidity rate was 52,9% according Clavien\u2013Dindo Classification. Anyway only 10.9% of patients were affected by grade III or IV complication with a mortality rate of 16.8%. At multivariate analysis the presence of a postoperative medical complication was the only predictive factor for mortality (OR 10.3; 95%CI 2.1-51.3 p=0.004) while the presence of COPD and purulent or fecal peritonitis were not statistically significant (OR 3.3; 95%CI 0.9-12.2 p=0.073 and OR 3.1 95%CI 0.8-11.6 p=0.099 respectively). For postoperative morbidity the logistic regression showed that patients 6575 years and with ASA score > 2 were independently associated with postoperative morbidity (OR 2.8; 95%CI 1.1-7.2 p=0.028 and OR 5.3 95%CI 2.0-13.9 p=0.001 respectively). The same factors were independent prognostic factor associated with medical complication with OR 3.0; 95%CI 1.1-7.8 p=0.028 and OR 6.5 95%CI 2.0-21.3 p=0.002 respectively. Multivariate analysis of factor predicting surgical morbidity showed that age 6575 was the only predictive factor for postoperative surgical morbidity (OR 3.1; 95%CI 1.1-8.8 P=0.027). Conclusioni In our experience the majority of patients who require surgery for CAD are at the first episode of acute diverticulitis. Medical complication after surgery for CAD is the only factor associated with mortality while surgical complications do not seem to have the same weight. Age 6575 years and ASA score >2 are independent predictive factors for postoperative medical complications while only age seems to have a significant effect on surgical morbidity

SHORT TERM RESULTS OF ELECTIVE COLON RESECTIONS FOR UNCOMPLICATED DIVERTICULAR DISEASE

Introduzione Indications for elective surgery in diverticular disease are sill debated and recent findings suggest a conservative approach since most patients present complicated diverticulitis as the first manifestation of diverticular disease. In our study we analyze the result in term of postoperative morbidity and mortality in patiets who underwent elective surgery for diverticular disease. Pazienti e metodi From September 2011 to May 2015 we perfomerd 170 surgical interventions for diverticular disease in our unit. Of these, 51 resection were performed in elective setting. Pre-, intra- and postoperative findings were collected in a prospective database. Multivariate analysis with logistic regression was performed to find out independent predictive factors for postoperative events. Statistical analysis was made with SPSS v.13.0 and significance was considered with p value < 0.05. Risultati Male:Female ratio was 1:1 with mean age of 59\uf0b114 years. 44 patients was younger than 75 years. 54.9% of patients had one or more comorbidities and 12 patients (23.5%) had ASA score >2. Most patients had only one previous hospital admission (28 patients, 54.9&) while 9 patients reported two or more admissions. 2 patient underwent surgery for the development of colo-vescical or colovaginal fistula and 2 patient for paracolic or pelvic abscess refractory to medical therapy. In 70.6% (36 patients) of cases a laparoscopic approach was performed with a conversion rate of 16.7%. No postoperative in-hospital mortality was recorded. Postoperative complication rate was 31.4% (16 patients) according Clavien-Dindo Classification. Anyway 14 patients had grade I or II complication with mild clinical impairment. Multivariate analysis did not find any independent predictive factor for overall and surgical complications. On the other hand presence of diabetes mellitus (DM) and ASA score > 2 was associated with increased risk of medical complication (OR 16.7; 95%CI 1.1-259.9 P=0.044 and OR 8.5; 95%CI 1.1-62.6 P=0.036 respectively). A T-test was performed to compare mean of postoperative stay within the two variables. Patients with ASA score > 2 were found to have longer postoperative stay respect to those with ASA score 1-2 (13,5 vs 8,4 P=0.008). No significant difference was found in patients with or without DM (9.0 vs 9.6 P=0.818). Conclusioni In our experience, elective surgery for diverticular disease can be performed safely and often with mini-invasive approach, with accetable rate of significant postoperative event. Anyway we need powerful studies providing strong evidence to identify patients who could really take advantage of elective surgical intervention

FEATURE IN YOUNG PATIENTS SURGICALLY TREATED FOR ACUTE DIVERTICULITIS

Introduzione There is lack of consensus whether to consider acute diverticulitis in younger patients a more aggressive disease than in other. While some authors considered diverticulitis in younger worst than in older patients, others suggested similar outcomes. In this study we evaluate differences between patients \uf0a3 45 years old and > 45 who underwent surgery for acute diverticulitis. Pazienti e metodi From September 2011 to May 2015 119 patients underwent emergency surgical intervention for acute diverticulitis in our unit. Pre-, intra- and postoperative findings were collected in a prospective database. 12 patients (Group A, 10,1%) were \uf0a3 45 years old. We compared clinical and pathological data between Group A patients and the remaining 145 (Group B 89.9) to find out any difference for characteristics of patients, clinical presentation, operative and short-term results. Uni- and multivaiate analysis were performed with SPSS v. 13.0 and satistical significance considered with p value < 0.05. Risultati Slight difference between Group A and Group B was found about presence of males (75.0% vs 43.9%; p=0.065). Significant differences were found for patients with one ore more comorbidities (16.7% vs 86.9%; p<0.001) and in particular for cardiovascular diseases (0% vs 67.3; p<0.001). Also ASA score was lower in younger patients with ASA 1-2 in 91.7% of patients versus 29.0% in group B patients (p<0.001). Localization of disease differed between two group with prevalence of right colonic side in 41.7% of Group A patients rspect to 10.3% of older patients (p=0.010). Group A patients treated in emergency were at first admission in 91.7% of cases respect to 83.2% of group B but this difference was not found to be statistically significant (p=0.688). In group A, laparoscopy was performed in 50% of patients while in group B only in 20.6% of cases (p=0.033) with no difference in conversion rate. The majority of Group A patients did not required an ostomy after surgical exploration respect to Group B patients (33.3% vs 74.8% p=0.006). No significant difference was found for the incidence of purulent or fecal generalized peritonitis (33.3% vs 57.9%; p=0.131). For postoperative results, morbidity rate according Clavien-Dindo classification was lower in Group A patients (8.3% vs 57.9%; p=0.001) and also the incidence of medical complications favoured younger patients (8.3% vs 44.9%; p=0.015). On the other hand the two groups did not differ for postoperative mortality (8.3% vs 17.8% p=0.688). Mean length of postoperative stay was shorter in Group A patients respect to Group B (6.3\uf0b12.0 vs 15.3\uf0b114.6; p=0.002). Multivariate analysis between Group A and B showed only a higher incidence of ostomy after surgery in group B (HR 4.0; 95%CI0.85-19.0) that did not reached statistical significance (p=0.08). Conclusioni Acute diverticulitis in young patients shows some peculiar issues, in particular for the localization of the disease, but does not seem to be more aggressive than in older people. For these reasons surgical intervention should be taken into account not considering age but the actual clinical, laboratoristic and instrumental findings

SURGERY FOR COLO-RECTAL CANCER: ADEQUACY OF NODAL STAGING IN AN EMERGENCY SETTING.

Background: It is a commonly held belief that in emergency surgery is not rare an inadequate lymphadenectomy resulting in pathologically understaged or indeterminate staging of the patient. Consequently some patients may not receive a necessary adjuvant chemotherapy or be subjected to unnecessary therapy. Methods: From September 2011 to May 2015, 483 patients were admitted in our Unit with the diagnosys of colo-rectal cancer. Four-hundred and fifty-five underwent to radical resection and were enrolled in this study. One-hundred and fifty-seven patients (35%) required an emergency operation (Group 1) and 298 (65%) had elective surgery (Group 2). Patients information were entered into a database: age and sex, tumor site, type of resection, laparoscopic versus open approach, stage, number of nodes and adequacy of lymph-node harvest (adequacy >= 12 lymph-nodes harvested). Statistical analysis was performed with SPSS v13; significance was defined as p< 0,05. Results: In Group 1, tumor sites were: right-sided 46%, left sided 45% and 9 % rectum. In Group 2, tumor sites were right-sided 38%, left sided 31% and 31 % rectum. These differences were statistically significant. The number of nodes harvested was similar in the two groups (Group 1: 18,3\ub19,2 nodes; Group 2: 18,7\ub110,1 nodes, p=0,97). The adequacy of lymph node harvest was 95% in Group 1 and 89% in Group 2. Thus the adequacy of lymphadenectomy was better in Group 1, however these differences were not statistically significant (p=0,60). The number of nodes harvested and the adequacy of lymphadenectomy were not influenced by the type of surgical approach (laparoscopic versus open surgery). Group 1 patients had a more advanced cancer stage (stage III/IV 47,1% vs. 36,0%, p=0,0006), but the need for enlarged resection was not significantly different in the two groups. Conclusions: Our data didn\u2019t show significant differences in nodes harvesting in emergency colo-rectal surgery compared to elective surgery. Adequacy of lymphadenectomy is comparable in the two settings

EMERGENCY COLO-RECTAL SURGERY IN PATIENTS OVER EIGHTY.

Background: Today average life expectancy in Western Countries has reached 80 years. At the same time, colorectal cancer (CCR) ranks first on both cancer incidence and related mortality. Therefore we face the problem of treating colorectal cancer occurring in elderly patients. Over the last years, there has been growing evidence in the literature that to this population should be offered life-prolonging radical surgeries. The aim of this study is to assess the clinical features and postoperative outcomes in 80 years old and older patients treated for colorectal cancer. We focused on safety (complication rates and operative mortality) and oncological results (radical excision and number of lymph nodes isolated). Methods: From September 2011 to May 2015, 483 resections for CCR with curative intent were performed; 16 explorative laparotomy and 12 trans-anal resection were excluded. Four hundred and fifty-five patients were enrolled: 307 of them were younger than 80 years and 168 patients were 80 years old or older. Patients\u2019 demographic, clinical and histopathological parameters, as well as intra- and perioperative results were analysed. Statistical analysis was performed with SPSS v13.0; significance was defined as p < 0.05. Results: Significant differences between the two groups were observed regarding comorbidities (p<0.001), cardio-vascular comorbidities and chronic renal failure in particular, emergency presentation (p<0.001), intraoperative blood transfusions (p=0.015), laparoscopic approach (p=0.002) and mortality (p<0.001). No differences were observed between the two groups regarding the number of radical resection and number of lymph nodes isolated. However, multivariate logistic regression analysis showed that advanced geriatric age ( 6580 years old) is an independent predictor of mortality (p=0.003 OR 4.756) but not an independent predictor of morbidity (p=0.669 OR 1.109); in particular, advanced geriatric age, emergency presentation and intraoperative blood transfusions are predictive of mortality; instead the presence of cardio-vascular comorbidities and emergency presentation, are independent predictor factors of morbidity. Conclusion: Old age ( 6580) as such does not represent a contraindication for CCR surgical treatment though associated with an increased risk of postoperative morbidity and mortality. In our opinion, patients who are appropriately evaluated and selected might have a favourable prognosis after undergoing colorectal resection

EMERGENCY COLO-RECTAL SURGERY IN PATIENTS OVER EIGHTY.

Introduction: Today average life expectancy in Western Countries has reached 80 years. At the same time, colorectal cancer (CRC) ranks first on both cancer incidence and related mortality. Therefore we face the problem of treating colorectal cancer occurring in elderly patients. Over the last years, there has been growing evidence in the literature that this population should be offered life-prolonging radical surgeries. The aim of the study is to assess clinical features and postoperative outcomes in 80 years old and older patients treated for CRC. We focused on safety (complication rates and operative mortality) and oncological results (radical excision and number of isolated lymph nodes). Methods: From September 2011 to May 2015, 455 resections for CRC with curative intent were performed: 148 patients were over 80 years old (GroupA), 307 patients were younger than 80 years (GroupB). Patients\u2019 demographic, clinical and histo-pathological parameters, as well as intra- and perioperative results were analysed. Results: In GroupA 72 patients underwent emergency procedures (49%) and 76 underwent elective procedures (51%); conversely in GroupB 85 patients underwent emergency procedures (53%) and 76 underwent elective procedures (47%), respectively (p<0.001). Significant differences between the two groups were observed regarding comorbidities, cardio-vascular comorbidities and chronic renal failure in particular, emergency presentation, intraoperative blood transfusions, laparoscopic approach and mortality (p<0.001). No differences were observed between the two groups regarding the number of radical resection and number of lymph nodes isolated. However, multivariate logistic regression analysis showed that advanced geriatric age ( 6580 years old) is an independent predictor of mortality (p=0.003 OR 4.756) but not an independent predictor of morbidity (p=0.669 OR 1.109); in particular, old age, emergency presentation (EP) and intraoperative blood transfusions are predictive of mortality; instead the presence of cardio-vascular comorbidities and EP, are independent predictor factors of morbidity. Conclusion: Old age ( 6580) as such does not represent a contraindication for CRC surgical treatment though associated with an increased risk of postoperative morbidity and mortality, above on emergency procedures In our opinion it is advisable to reduce emergency procedures with multidisciplinary methods such as stenting in CRC obstruction as a bridge to surgery

Kidney and uro-trauma: WSES-AAST guidelines

Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines

The unrestricted global effort to complete the COOL trial

Background Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) (https://clinicaltrials.gov/ct2/show/NCT03163095). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.Methods The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.Discussion OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. Trial registration: National Institutes of Health (https://clinicaltrials.gov/ct2/show/NCT03163095). Keywords Intraperitoneal sepsis, Septic shock, Peritonitis, Open abdomen, Multiple organ dysfunction, Laparotomy, Randomized controlled trial, Global healthPeer reviewe