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)

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception

ALTERATIONS OF GLYCOSAMINOGLYCANS IN VARICOSE VEINS

QUANTITATIVE AND QUALITATIVE ALTERATIONS OF GLYCOSAMINOGLYCANS WERE INCREASED IN THE GREATER SAPHENOUS VEINS TAKEN FROM 20 PATIENTS WITH PRIMARY VENOUS INSUFFICIENCY OF THE LOW EXTREMETIES WHO HAD VENOUS STRIPING. SAMPLES WERE TAKEN FROM THE VARICOSE VEIN, FROM THE MACROSCOPICALLY NORMAL SEGMENT NEAR THE VARICOSE VEIN AND FROM THE INTERMEDIATE SEGMENT. IT WAS FOUND THAT THE LEVELS OF GLYCOSAMINOGLYCANS IN THE VARICOSE VEINS AND IN THE INTERMEDIATE SEGMENTS WERE ELEVATED COMPARED TO THE NORMAL SEGMENTS. QUALITATIVE CHANGES OF THE GLYCOSAMINOGLYCANS WERE NOT FOUND. QUANTITATIVE CHANGES WERE CONFIRMED BY THE HISTOCHEMICAL FINDINGS WITH SPECIAL STRAINS. THE POSSIBLE IMPLICATIONS OF OUR RESULTS ARE DISCUSSED.ΜΕΛΕΤΗΘΗΚΑΝ ΟΙ ΠΟΣΟΤΙΚΕΣ ΚΑΙ ΠΟΙΟΤΙΚΕΣ ΜΕΤΑΒΟΛΕΣ ΤΩΝ ΓΛΥΚΟΖΑΜΙΝΟΓΛΥΚΑΝΩΝ ΣΕ ΜΕΙΖΟΝΕΣ ΣΑΦΗΝΕΙΣ ΦΛΕΒΕΣ ΠΟΥ ΕΛΗΦΘΗΣΑΝ ΑΠΟ 20 ΑΣΘΕΝΕΙΣ ΠΟΥ ΕΠΑΣΧΑΝ ΑΠΟ ΠΡΩΤΟΠΑΘΗ ΦΛΕΒΙΚΗ ΑΝΕΠΑΡΚΕΙΑ ΤΩΝ ΚΑΤΩ ΑΚΡΩΝ ΚΑΙ ΕΙΧΑΝ ΥΠΟΣΤΕΙ ΣΑΦΗΝΕΚΤΟΜΗ. ΕΞΕΤΑΣΘΗΚΑΝ ΤΟΚΙΡΣΩΔΕΣ ΤΜΗΜΑ ΤΗΣ ΦΛΕΒΑΣ, ΤΟ ΜΑΚΡΟΣΚΟΠΙΚΑ ΦΥΣΙΟΛΟΓΙΚΟ ΚΑΙ ΤΟ ΕΝΔΙΑΜΕΣΟ ΤΜΗΜΑ. ΒΡΕΘΗΚΕ ΟΤΙ ΟΙ ΓΛΥΚΟΖΑΜΙΝΟΓΛΥΚΑΝΕΣ ΤΩΝ ΚΙΡΣΩΔΩΝ ΚΑΙ ΤΩΝ ΕΝΔΙΑΜΕΣΩΝ ΤΜΗΜΑΤΩΝ ΠΑΡΟΥΣΙΑΖΟΥΝ ΑΥΞΗΜΕΝΗ ΣΥΓΚΕΝΤΡΩΣΗ ΣΕ ΣΧΕΣΗ ΜΕ ΤΑ ΦΥΣΙΟΛΟΓΙΚΑ ΤΜΗΜΑΤΑ. ΔΕΝ ΚΑΤΑΔΕΙΧΘΗΚΑΝ ΠΟΙΟΤΙΚΕΣ ΔΙΑΦΟΡΕΣ, ΣΥΜΒΑΔΙΖΟΥΝ ΜΕ ΤΑ ΔΕΔΟΜΕΝΑ ΠΟΥ ΠΡΟΚΥΠΤΟΥΝ ΑΠΟ ΤΗΝ ΜΙΚΡΟΣΚΟΠΙΚΗ ΜΕΛΕΤΗ ΤΩΝ ΔΕΙΓΜΑΤΩΝ ΜΕ ΕΙΔΙΚΕΣ ΓΙΑ ΤΗΝ ΑΝΑΔΕΙΞΗ ΤΩΝ ΓΛΥΚΟΖΑΜΙΝΟΓΛΥΚΑΝΩΝ ΧΡΩΣΕΙΣ. ΣΥΖΗΤΟΥΝΤΑΙ ΟΙ ΠΙΘΑΝΕΣ ΔΙΑΣΤΑΣΕΙΣ ΤΩΝ ΕΥΡΗΜΑΤΩΝ ΜΑΣ

An unusual cause of large bowel obstruction: are we aware of this?

Primary lymphomas of the colon account for 0.5% of all primary colon malignancies. Burkitt´s lymphoma is a B-cell lymphoma with aggressive clinical behavior. Herein, we describe a case of a male patient who presented with signs of large bowel obstruction, underwent surgery and found to suffer from Burkitt´s lymphoma of the ileocecal region. The histopathological examination was indicative for Burkitt´s lymphoma. To the best of our insight this is one of the few reported cases of such type of lymphoma in an adult patient presenting with bowel obstruction. Burkitt´s lymphoma is a rare malignancy in adults affecting gastrointestinal tract. It has a high proliferation potential and can rapidly progress to advanced disease. Early diagnosis is necessary to prevent complications and improve overall prognosis

New Mediterranean Marine biodiversity records (June 2013)

This paper concerns records of species that have extended their distribution in the Mediterranean Sea. The finding of the rare brackish angiosperm Althenia filiformis in the island of Cyprus is interesting since its insertion in the Red Data Book of the Flora of Cyprus is suggested. The following species enriched the flora or fauna lists of the relevant countries: the red alga Sebdenia dichotoma (Greece), the hydrachnid mite Pontarachna adriatica (Slovenia), and the thalassinid Gebiacantha talismani (Turkey). Several alien species were recorded in new Mediterranean localities. The record of the burrowing goby Trypauchen vagina in the North Levantine Sea (Turkish coast), suggests the start of spreading of this Lessepsian immigrant in the Mediterranean Sea. The findings of the following species indicate the extension of their occurrence in the Mediterranean Sea: the foraminifer Amphistegina lobifera (island of Zakynthos, Greece), the medusa Cassiopea andromeda (Syria), the copepod Centropages furcatus (Aegean Sea), the decapod shrimp Melicertus hathor (island of Kastellorizo, Greece), the crab Menoethius monoceros (Gulf of Tunis), the barnacles Balanus trigonus, Megabalanus tintinnabulum, Megabalanus coccopoma and the bivalves Chama asperella, Cucurbitula cymbium (Saronikos Gulf, Greece).JRC.H.1-Water Resource

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND: The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not. METHODS: Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not. RESULTS: A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001]. CONCLUSIONS: The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands

Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis

IMPORTANCE Considering the lack of equipoise regarding the timing of cholecystectomy in patients with moderately severe and severe acute biliary pancreatitis (ABP), it is critical to assess this issue.OBJECTIVE To assess the outcomes of early cholecystectomy (EC) in patients with moderately severe and severe ABP.DESIGN, SETTINGS, AND PARTICIPANTS This cohort study retrospectively analyzed real-life data from the MANCTRA-1 (Compliance With Evidence-Based Clinical Guidelines in the Management of Acute Biliary Pancreatitis) data set, assessing 5304 consecutive patients hospitalized between January 1, 2019, and December 31, 2020, for ABP from 42 countries. A total of 3696 patients who were hospitalized for ABP and underwent cholecystectomy were included in the analysis; of these, 1202 underwent EC, defined as a cholecystectomy performed within 14 days of admission. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality and morbidity. Data analysis was performed from January to February 2023.MAIN OUTCOMES Mortality and morbidity after EC.RESULTS Of the 3696 patients (mean [SD] age, 58.5 [17.8] years; 1907 [51.5%] female) included in the analysis, 1202 (32.5%) underwent EC and 2494 (67.5%) underwent delayed cholecystectomy (DC). Overall, EC presented an increased risk of postoperative mortality (1.4% vs 0.1%, P &lt;.001) and morbidity (7.7% vs 3.7%, P &lt; .001) compared with DC. On the multivariable analysis, moderately severe and severe ABP were associated with increased mortality (odds ratio [OR], 361.46; 95% CI, 2.28-57 212.31; P = .02) and morbidity (OR, 2.64; 95% CI, 1.35-5.19; P = .005). In patients with moderately severe and severe ABP (n = 108), EC was associated with an increased risk of mortality (16 [15.6%] vs 0 [0%], P &lt; .001), morbidity (30 [30.3%] vs 57 [5.5%], P &lt; .001), bile leakage (2 [2.4%] vs 4 [0.4%], P = .02), and infections (12 [14.6%] vs 4 [0.4%], P &lt; .001) compared with patients with mild ABP who underwent EC. In patients with moderately severe and severe ABP (n = 108), EC was associated with higher mortality (16 [15.6%] vs 2 [1.2%], P &lt; .001), morbidity (30 [30.3%] vs 17 [10.3%], P &lt; .001), and infections (12 [14.6%] vs 2 [1.3%], P &lt; .001) compared with patients with moderately severe and severe ABP who underwent DC. On the multivariable analysis, the patient's age (OR, 1.12; 95% CI, 1.02-1.36; P = .03) and American Society of Anesthesiologists score (OR, 5.91; 95% CI, 1.06-32.78; P = .04) were associated with mortality; severe complications of ABP were associated with increased mortality (OR, 50.04; 95% CI, 2.37-1058.01; P = .01) and morbidity (OR, 33.64; 95% CI, 3.19-354.73; P = .003).CONCLUSIONS AND RELEVANCE This cohort study's findings suggest that EC should be considered carefully in patients with moderately severe and severe ABP, as it was associated with increased postoperative mortality and morbidity. However, older and more fragile patients manifesting severe complications related to ABP should most likely not be considered for EC

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago /

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann’s procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100 years since the first Hartmann’s procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment’s choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception