La timpanoplastica aperta: indicazioni e nostri risultati a distanza

OBIETTIVI Le indicazioni per una tecnica aperta sono in primo luogo le otomastoiditi colesteatomatose, le neoplasie, alcune complicanze ed alcune forme di otomastoidite granulomatosa diffusa con totale coinvolgimento della catena ossiculare, specialmente quando esiste una mastoide eburmnea. MATERIALI Nel periodo 1975‐2006 sono state eseguite 4875 timpanoplastiche, di cui 3343 con tecnica aperta. In considerazione dell'esperienza maturata è utile distinguere un periodo compreso tra il 1975 e 1990, nel quale, indipendentemente dalla diagnosi, si eseguiva la tecnica chiusa nel 95% dei casi, mentre la tecnica aperta era riservata al 5% dei casi. Nell'85% delle tecniche chiuse veniva eseguito un secondo tempo a distanza di 8 mesi: nel 30% dei casi si trovava una recidiva del colesteatoma, per cui si passava ad una tecnica aperta. Per questi risultati si è deciso di invertire il nostro modo di operare ed abbiamo eseguito la tecnica aperta nel 90% delle otomastoiditi colesteatomatose. RIASSUNTO Abbiamo valutato i risultati a distanza di 4 anni trovando: ‐ recidiva del colesteatoma 5% ‐ risultati anatomici: buona conservazione del neotimpano 40%, perforazione del neotimpano 45%, totale riassorbimento del neotimpano 15%. ‐ risultati funzionali: abbiamo preso in considerazione l'indice GAP (la somma della perdita di udito preoperatoria per le frequenze 250,500,1000,2000 fratto la somma della perdita di udito postoperatoria per le stesse frequenze), nel quale l'indice > di 3 indica risultato ottimo, l'indice > di 2 indica risultato buono, l'indice < di 2 indica risultato insoddisfacente, l'indice < di 1 indica risultato peggiorativo. Nella nostra casistica abbiamo ottenuto GAP > di 3 nel 15% dei casi, GAP > di 2 nel 40%, GAP < di 2 nel 20%,GAP < di 1 nel 5%. CONCLUSIONI In conclusione la migliore visualizzazione della cavità mastoidea consente di prevenire la recidiva di colesteatoma; il paziente può fare il bagno al mare se la guarigione è ben consolidata. Dal punto di vista funzionale non esistono notevoli differenze tra tecnica chiusa e tecnica aperta ed oggi è possibile una corretta protesizzazione anche nei soggetti operati con tecnica aperta. Noi non eseguiamo una ricostruzione della cavità mastoidea prima dei 2 anni dal primo intervento

Prognostic factors influencing infectious complications after cytoreductive surgery and HIPEC. Results from a tertiary referral center

Background. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) showed promising results in selected patients. High morbidity restrains its wide application. The aim of this study was to report postoperative infectious complications and investigate possible correlations with preoperative nutritional status and other prognostic factors in patients with peritoneal metastases treated with CRS and HIPEC. Methods. For the study we reviewed the clinical records of all patients with peritoneal metastases from different primary cancers and treated by CRS and HIPEC in our Institution from November 2000 to December 2017. Patients were divided according to their nutritional status (SGA) in group A (well-nourished), B/C (mild or severely malnourished). Possible statistical correlations between risk factors and postoperative complications rates have been investigated by univariate and multivariate analysis. Results. Two hundred patients were selected and underwent CRS and HIPEC during the study period. Postoperative complications occurred in 44% of the patients, 35.3% in SGA-A patients and 53% in SGA-B /C patients. Cause of complications was infective in 42, non-infective in 37 and HIPEC related in 9 patients. Infectious complications occurred more frequently in SGA-B /C patients (32.6% vs. 9.8% of SGA-A patients). The most frequent sites of infection were Surgical Site Infections (SSI, 35.7%) and Central Line Associated BloodStream Infections (CLABSI, 26.2%). The most frequent isolated species was Candida (22.8%). ASA score, blood loss, performance status, PCI, large bowel resection, postoperative serum albumin levels and nutritional status correlated with higher risk for postoperative infectious complications. Conclusions. Malnourished patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are more prone to post-operative infectious complications and adequate perioperative nutritional support should be considered, including immune-enhancing nutrition. Sequential monitoring of common sites of infection, antifungal prevention of candidiasis, and careful patient selection should be implemented to reduce complications rate

Emangiopericitoma Vs Tumore glomico

OBIETTIVI I tumori che originano dalle cellule di supporto dei vasi, i periciti, appartengono alla vasta categoria dei tumori dei tessuti molli che sono lesioni generalmente frequenti nel distretto testa-collo. La trasformazione in senso neoplastico dei periciti è comunque poco frequente e può dare origine a due gruppi neoplastici: i tumori glomici e l’emangiopericitoma. Gli autori presentano in seno alla stessa famiglia due casi clinici rispettivamente di tumori glomico timpanico e di emangiopericitoma del condotto uditivo esterno. MATERIALI I tumori glomici timpanici e giugulari sono rare neoformazioni ipervascolarizzate, a lenta crescita, che si sviluppano nell’ambito dell’orecchio medio e dell’osso temporale; fanno parte di un gruppo di tumori, definiti paragangliomi, che prendono origine da un sistema di cellule derivanti dalla cresta neurale. Esistono delle forme familiari in cui si possono osservare delle lesioni multicentriche, con comparsa sincrona delle lesioni o metacrona, rientrando così in quel gruppo di tumori definito MEN II (neoplasie endocrine multiple tipo II). Ad oggi i loci genici chiamati in causa come responsabili dell’ereditarietà sono definiti: PGL1 codificante per la Succinato Deidrogenasi sub-unità D (SDHD), PGL3 (codificante per SDHC) e PGL4 (codificante per SDHB) localizzati tutti sul cromosoma 11 (11q23-11q13.1). Il locus genico PGL2 non è stato ancora ben identificato. Anche il locus 1q21-q23 può essere responsabile di una forma familiare. L’emangiopericitoma (HPC) è un tumore vascolare maligno che insorge dalle cellule mesenchimali con differenziazione pericitica (periciti di Zimmerman). Il profilo immunoistochimico dell'HPC è incerto e la diagnosi è di solito controversa. La diagnosi differenziale con il sarcoma sinoviale, il condrosarcoma mesenchimale, l'istiocitoma fibroso e il tumore fibroso solitario è problematica. Sono state identificate anomalie cromosomiche (traslocazioni) in alcuni emangiopericitomi in particolare t(x;18)(p11.2;q11.2) ma ad oggi non sono state riscontrate delle forme familiari. RIASSUNTO Gli autori presentano due casi clinici rispettivamente di tumori glomico timpanico e di emangiopericitoma del condotto uditivo esterno di due soggetti appartenenti alla stessa famiglia analizzando le differenti caratteristiche cliniche, audiologiche ed istologiche delle forme neopastiche. CONCLUSIONI Gli autori ipotizzano una origine genetica analoga per le neoplasia sopradescritte che potrebbe essere ricondotta alla inattivazione del gene di Von Hippel-Lindau

Increased levels of palmitoylethanolamide and other bioactive lipid mediators and enhanced local mast cell proliferation in canine atopic dermatitis

Background: Despite the precise pathogenesis of atopic dermatitis (AD) is unknown, an immune dysregulation that causes Th2-predominant inflammation and an intrinsic defect in skin barrier function are currently the two major hypotheses, according to the so-called outside-inside-outside model. Mast cells (MCs) are involved in AD both by releasing Th2 polarizing cytokines and generating pruritus symptoms through release of histamine and tryptase. A link between MCs and skin barrier defects was recently uncovered, with histamine being found to profoundly contribute to the skin barrier defects. Palmitoylethanolamide and related lipid mediators are endogenous bioactive compounds, considered to play a protective homeostatic role in many tissues: evidence collected so far shows that the anti-inflammatory effect of palmitoylethanolamide depends on the down-modulation of MC degranulation. Based on this background, the purpose of the present study was twofold: (a) to determine if the endogenous levels of palmitoylethanolamide and other bioactive lipid mediators are changed in the skin of AD dogs compared to healthy animals; (b) to examine if MC number is increased in the skin of AD dogs and, if so, whether it depends on MC in-situ proliferation. Results: The amount of lipid extract expressed as percent of biopsy tissue weight was significantly reduced in AD skin while the levels of all analyzed bioactive lipid mediators were significantly elevated, with palmitoylethanolamide showing the highest increase. In dogs with AD, the number of MCs was significantly increased in both the subepidermal and the perifollicular compartments and their granule content was significantly decreased in the latter. Also, in situ proliferation of MCs was documented. Conclusions: The levels of palmitoylethanolamide and other bioactive lipid mediators were shown to increase in AD skin compared to healthy samples, leading to the hypothesis that they may be part of the body's innate mechanisms to maintain cellular homeostasis when faced with AD-related inflammation. In particular, the increase may be considered a temptative response to down-regulating the observed elevation in the number, functionality and proliferative state of MCs in the skin of AD dogs. Further studies are warranted to confirm the hypothesis

The role of procalcitonin in reducing antibiotics across the surgical pathway

Procalcitonin (PCT) is widely considered as a highly sensitive biomarker of bacterial infection, offering general and emergency surgeons a key tool in the management of surgical infections. A multidisciplinary task force of experts met in Bologna, Italy, on April 4, 2019, to clarify the key issues in the use of PCT across the surgical pathway. The panelists presented the statements developed for each of the main questions regarding the use of PCT across the surgical pathway. An agreement on the statements was reached by the Delphi method, and this document reports the executive summary of the final recommendations approved by the expert panel

Extramedullary plasmacytoma of the tonsil: A new management

Introduction: Extramedullary plasmacytoma (EMP) is a rare tumor of all plasma cell neoplasms. The tumor is mainly localized in the head and neck region, but rarely involving the tonsil. Case presentation: The authors report the 5th case of EMP of the tonsil in the literature occurred in a 57-year-old Caucasian male. Conclusions: Through a review of the relevant literature, we consider adjuvant radiotherapy not necessary for EMP of tonsil because of an adequate resection achieved by surgery

Giant inframuscular lipoma disclosed 14 years after a blunt trauma: A case report

<p>Abstract</p> <p>Introduction</p> <p>Lipoma is the most frequent benign tumor of the soft tissue. This lesion is often asymptomatic except in cases of enormous masses compressing nervous-vascular structures. Although the diagnosis is mostly clinical, imaging tools are useful to confirm the adipose nature of the lesion and to define its anatomic border. Sometimes, lipomas may be the result of a previous trauma, such as in this patient.</p> <p>Case presentation</p> <p>A 45-year-old man presented at our institution with a giant hard firm mass in the upper external quadrant of the right buttock disclosed after a weight loss diet. Subsequent magnetic resonance imaging showed a giant adipose mass developed beneath the large gluteal muscle and among the fibers of the medium and small gluteal muscles. When questioned on his medical history, the patient reported a blunt trauma of the lower back 14 years earlier. He underwent surgery and histological examination confirmed a giant lipoma.</p> <p>Conclusion</p> <p>Lipomas might result from a previous trauma. It is hypothesized that the trigger mechanism is activated by cytokine and growth factors released after the trauma. We herein present an exceptional case of a giant post-traumatic lipoma which caused a painful compression on the right sciatic nerve.</p

Increased endocannabinoid levels reduce the development of precancerous lesions in the mouse colon

Colorectal cancer is an increasingly important cause of death in Western countries. Endocannabinoids inhibit colorectal carcinoma cell proliferation in vitro. In this paper, we investigated the involvement of endocannabinoids on the formation of aberrant crypt foci (ACF, earliest preneoplastic lesions) in the colon mouse in vivo. ACF were induced by azoxymethane (AOM); fatty acid amide hydrolase (FAAH) and cannabinoid receptor messenger ribonucleic acid (mRNA) levels were analyzed by the quantitative reverse transcription polymerase chain reaction (RT-PCR); endocannabinoid levels were measured by liquid chromatography–mass spectrometry; caspase-3 and caspase-9 expressions were measured by Western blot analysis. Colonic ACF formation after AOM administration was associated with increased levels of 2-arachidonoylglycerol (with no changes in FAAH and cannabinoid receptor mRNA levels) and reduction in cleaved caspase-3 and caspase-9 expression. The FAAH inhibitor N-arachidonoylserotonin increased colon endocannabinoid levels, reduced ACF formation, and partially normalized cleaved caspase-3 (but not caspase-9) expression. Notably, N-arachidonoylserotonin completely prevented the formation of ACF with four or more crypts, which have been show to be best correlated with final tumor incidence. The effect of N-arachidonoylserotonin on ACF formation was mimicked by the cannabinoid receptor agonist HU-210. No differences in ACF formation were observed between CB1 receptor-deficient and wild-type mice. It is concluded that pharmacological enhancement of endocannabinoid levels (through inhibition of endocannabinoid hydrolysis) reduces the development of precancerous lesions in the mouse colon. The protective effect appears to involve caspase-3 (but not caspase-9) activation

Will the COVID-19 pandemic transform infection prevention and control in surgery? Seeking leverage points for organizational learning

Background: In response to the coronavirus disease of 2019 (COVID-19) pandemic, healthcare systems worldwide have stepped up their infection prevention and control efforts in order to reduce the spread of the infection. Behaviours, such as hand hygiene, screening and cohorting of patients, and the appropriate use of antibiotics have long been recommended in surgery, but their implementation has often been patchy. Methods: The current crisis presents an opportunity to learn about how to improve infection prevention and control and surveillance (IPCS) behaviours. The improvements made were mainly informal, quick and stemming from the frontline rather than originating from formal organizational structures. The adaptations made and the expertise acquired have the potential for triggering deeper learning and to create enduring improvements in the routine identification and management of infections relating to surgery. Results: This paper aims to illustrate how adopting a human factors and ergonomics perspective can provide insights into how clinical work systems have been adapted and reconfigured in order to keep patients and staff safe. Conclusion: For achieving sustainable change in IPCS practices in surgery during COVID-19 and beyond we need to enhance organizational learning potentials

SARS-CoV-2 pandemic. Implications in the management of patients with colorectal cancer

The SARS-CoV-2 pandemic has already reached 3,207,248 patients with more than 225,000 deaths all over the world. Colorectal cancer is the third most diagnosed cancer worldwide, and the healthcare system is struggling to manage daily activities for elective cancer surgery. This review integrates clinical, microbiological, architectural and surgical aspects to develop indications on strategies to manage colorectal cancer patients and ensure safety during the pandemic. Telephone or virtual clinics must be encouraged and phone follow-up should be implemented. Indications for surgery must be rigorous, balancing the advantage of early surgical treatment and risks of treatment delay. To decrease the occupancy rate of intensive care unit beds, elective surgical treatment should be delayed until local endemic control, according to stage of disease. Patients with SARS-CoV-2 infection should be treated only after clinical recovery, two consecutive negative oropharyngeal swabs and, if available, a negative stool sample. Before any elective oncologic procedure, a multidisciplinary oncologic team including an anaesthesiologist and an infectious disease specialist must assess every patient to evaluate the risk of infection and its impact on perioperative morbidity, mortality and oncologic prognosis. The hospital should organise to manage all elective oncologic patients in an "infection-free" area or refer them to a non-SARS-CoV-2 hospital