Treatment of wounds colonized by multidrug resistant organisms in immune-compromised patients: a retrospective case series.

Immune-compromised patients incur a high risk of surgical wound dehiscence and colonization by multidrug resistant organisms. Common treatment has been debridement and spontaneous secondary healing.All immune-compromised patients referred to our Institution between March 1, 2010 and November 30, 2011 for dehiscent abdominal wounds growing multidrug resistant organisms were treated by serial wound debridements and negative pressure dressing. They were primarily closed, despite positive microbiological cultures, when clinical appearance was satisfactory.Nine patients were treated by direct wound closure, five had been treated previously by secondary intention healing.According to our results, fast healing can be safely obtained by closure of a clinically healthy wound, despite growth of multidrug resistant organisms, even in immune-compromised patients

Surgical Approach for Long-term Survival of Patients With Intrahepatic Cholangiocarcinoma: A Multi-institutional Analysis of 434 Patients.

OBJECTIVES To examine the outcomes of a hepatectomy for intrahepatic cholangiocarcinoma (IHC) and to clarify the prognostic impact of a lymphadenectomy and the surgical margin. Large series of patients who were surgically treated for IHC are scarce. Thus, prognostic factors and long-term survival after resection of IHC remain uncertain. DESIGN Prospective study of patients who were surgically treated for IHC. Clinicopathologic, operative, and long-term survival data were analyzed. SETTING Prospectively collected data of all consecutive patients with pathologically confirmed IHC who had undergone liver resection with a curative intent at 1 of 16 tertiary referral centers were entered into a multi-institutional registry. PATIENTS All consecutive patients who underwent a hepatectomy with a curative intent for IHC (1990-2008) were identified from a multi-institutional registry. RESULTS A total of 434 patients were included in the analysis. Most patients underwent a major or extended hepatectomy (70.0%) and a systematic lymphadenectomy (62.2%). The incidence of lymph node metastases (overall, 36.9%) increased with increased tumor size, with 24.4% of patients with a small IHC (diameter 643 cm) having N1 disease. Almost one-third of patients required an additional major procedure to obtain a R0 resection in 84.6% of the cases. In these patients, the median time of survival was 39 months, and the 5-year survival rate was 39.8%. Lymph node metastases (hazard ratio, 2.21; P < .001), multiple tumors (hazard ratio, 1.50; P = .009), and an elevated preoperative cancer antigen 19.9 level (hazard ratio, 1.62; P = .006) independently predicted an adverse prognosis. Conversely, survival was not influenced by the width of a negative resection margin (P = .61). The potential survival benefit of a lymphadenectomy was assessed with the therapeutic value index, which was calculated to be 5.9 points. CONCLUSIONS Survival rates after a hepatectomy with a curative intent for IHC at tertiary referral centers exceed the survival rates reported in most study series in single institutions, which strengthens the value of an aggressive approach to radical resection. Lymph node metastases and multiple tumors are associated with decreased survival rates, but they should not be considered selection criteria that prevent other patients from undergoing a potentially curative resection. Lymphadenectomy should be considered for all patients

Renal function at two years in liver transplant patients receiving everolimus: results of a randomized, multicenter study

Abstract In a 24-month prospective, randomized, multicenter, open-label study, de novo liver transplant patients were randomized at 30 days to everolimus (EVR) + Reduced tacrolimus (TAC; n = 245), TAC Control (n = 243) or TAC Elimination (n = 231). Randomization to TAC Elimination was stopped prematurely due to a significantly higher rate of treated biopsy-proven acute rejection (tBPAR). The incidence of the primary efficacy endpoint, composite efficacy failure rate of tBPAR, graft loss or death postrandomization was similar with EVR + Reduced TAC (10.3%) or TAC Control (12.5%) at month 24 (difference -2.2%, 97.5% confidence interval [CI] -8.8%, 4.4%). BPAR was less frequent in the EVR + Reduced TAC group (6.1% vs. 13.3% in TAC Control, p = 0.010). Adjusted change in estimated glomerular filtration rate (eGFR) from randomization to month 24 was superior with EVR + Reduced TAC versus TAC Control: difference 6.7 mL/min/1.73 m(2) (97.5% CI 1.9, 11.4 mL/min/1.73 m(2), p = 0.002). Among patients who remained on treatment, mean (SD) eGFR at month 24 was 77.6 (26.5) mL/min/1.73 m(2) in the EVR + Reduced TAC group and 66.1 (19.3) mL/min/1.73 m(2) in the TAC Control group (p < 0.001). Study medication was discontinued due to adverse events in 28.6% of EVR + Reduced TAC and 18.2% of TAC Control patients. Early introduction of everolimus with reduced-exposure tacrolimus at 1 month after liver transplantation provided a significant and clinically relevant benefit for renal function at 2 years posttransplant

SENTINEL NODE IN DIFFERENTIATED THYROID CANCER: COMPARISON BETWEEN VITAL-DYE PATENT BLUE, LYMPHOSCINTIGRAPHY AND COMBINED TECHNIQUE

Obiettivo dello studio : aim of the study is to evaluate the role of sentinel node (SN) identification in the treatment of differentiated thyroid cancer (DTC). We also aim to assess feasibility and reproducibility of the SN techniques with vital-dye patent blue, radiotracer and combined technique Materiali e metodi : the study is multicentric, prospective, randomized three arms open. We expect to enroll 120 patients in 2 years. Patients have to be preoperative diagnosis of DTC. Exclusion criteria are previous cervical surgery, medullary cancer, nodes metastasis and multifocal tumor. All patients undergo total thyroidectomy, SN identification and central compartment (CC) dissection: in Arm A SN identification is obtained with vital-dye Patent blue technique, in Arm B with lymphoscintigraphy and in Arm C with combined technique. Specimen histopathology provides information about the characteristics of primary tumor, SN and the remaining nodes with specific immuno-histochemistry protocols Principali risultati : so far we enrolled 42 patients Arm A (26 pts): 18 patients (69.2%) had negative SN and nonSN; 1 (3.8%) with negative SN had micrometastasis in 2 nodes of CC; 2 (7.6%) with macrometastasis in the SN had metastatic nodes in the CC and 1 (3.8%) had macrometastasis in the SN with no other positive nodes. In 4 (15.2%) patients identification of the SN wasn't possible and there was no evidence of metastasis in all nodes removed Arm B: 2 patients (100%) had negative SN and nonSN Arm C (14 pts): 4 patients (28.6%) had negative SN and nonSN; 1 (7.1%) with negative SN had macrometastasis in 2 nodes; 4 (28.6%) with macrometastasis in the SN had metastatic nodes in the CC and 1 (7.1%) had macrometastasis in the SN with no other positive nodes. In 4 (28.6%) patients identification of the SN wasn't possible and in 3 of them there was no evidence of metastasis Conclusioni : so far the data we gathered are too few to make statistic significant conclusions. Once adequate scientific evidence is available, detection of the SN could become a routine procedure in DTC treatment, avoiding central compartment dissection in patients with negative SN. The achievement of a standard protocol of SN detection remains an important issue to solve, although both techniques had shown a good rate of detection of the SN, several studies report that the combined method could reduce false negatives and increase detection rates of SN metastase

L’approccio endoscopico alla calcolosi della via biliare: acquisizione e sviluppo dell’esperienza in una Unità Operativa di Chirurgia Generale. Due periodi a confronto

Lo sviluppo della chirurgia laparoscopica ha fatto sorgere la necessità, presso molti Centri, di controllare e trattare endoscopica - mente l’eventuale litiasi della via biliare associata alla calcolosi della colecisti. La diffusione di tale metodica è sempre stata ostacolata da una sua discreta complessità organizzativa e tecnica e soprattutto dal rischio di complicanze; per tali motivi la tendenza (confortata da autorevoli pareri) è sempre stata quella di concentrare l’esecuzione di ERCP in Centri che ne praticassero molte e con grande frequenza. I risultati di questo studio, con il confronto tra il primo e l’ulti - mo anno completo di attività, indicano che si può acquisire la capa - cità necessaria a soddisfare le esigenze dell’Unità Operativa Chirurgica partendo dal volume di attività offerto dalla propria casi - stica attendendosi buoni risultati con bassa incidenza di complicanze

Long term persistence of low bone density in orthotopic liver transplantation

We determined bone density and metabolism in 46 patients (35 males, 11 females) who had undergone liver transplantation 1-48 months previously. Twenty-one patients were then followed for the next 24 months. At each visit, blood and urine samples for bone and liver metabolism parameters, as well as spinal and femoral dual-energy X-ray absorptiometry (DXA) scans, were obtained. Basal spinal and femoral density was low (p &lt; 0.001). Patients with pre-transplant cholestatic diseases had lower spinal density than all the other subjects (p &lt;0.05) and the cumulative methylprednisolone intake was an independent negative predictor of total hip density (p &lt; 0.02). At baseline, urinary hydroxyproline and N-telopeptide were at the upper normal level and decreased only after 24 months of follow-up (p &lt; 0.05). During the first year of follow-up, femoral density decreased (p &lt; 0.05) and a partial recovery was observed for both spine and femur after 24 months. After 12 months, femoral bone density was negatively associated with serum cyclosporin A levels (p &lt; 0.005) and cumulative methylprednisolone intake (p &lt; 0.05), while the percent decrease in spinal density after the first 12 months was negatively predicted by mean daily methylprednisolone intake (p &lt; 0.05). In patients with pre-transplant cholestatic diseases, femoral and spinal density increased after the first (p &lt; 0.05) and second year (p &lt; 0.05), respectively. In patients with previous post-necrotic cirrhosis, femoral density decreased after 12 months (p&lt;0.05) and was still lower than baseline after 24 months (p &lt; 0.05). However, at the end of the study the cumulative percentage of femoral neck osteoporosis was 43%. In conclusion, an elevated prevalence of spinal and femoral osteoporosis is present even many years after liver transplantation, with immunosuppressive treatment and pre-transplant liver disease being the most important pathogenetic factors

Which Is the Last Stage before Packing in Elective Liver Surgery?

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