Impact of office-based surgery for hemorrhoids on clinical outcomes and institutional costs: a prospective controlled study

Aim: Transanal hemorrhoidal artery ligation with mucopexy (THAL-m) is a treatment option for symptomatic hemorrhoidal disease (HD). Open hemorrhoidectomy (OH) has stood the test of time in terms of radical cure for HD. Both techniques can be performed under local anesthesia. The aim of this study was to determine the impact on postoperative outcome and cost-effectiveness of performing these techniques in ambulatory setting in an Italian academic centre. Method: A prospective series of grade II /III HD. 100 consecutive patients undergoing ambulatory surgical treatment of hemorrhoids in 2015–2017 (group A) were compared to 100 patients operated at the same institution in the same period (Group H) by hospitalization. The primary outcome was sick leave used as a proxy of clinical outcome. Secondary outcomes included postoperative complications, cost-effectiveness, and patient satisfaction. Results: Sick leave was significantly reduced in Group A patients (8 days versus 15) with no increase in postoperative complications, and patient satisfaction was high. Total mean direct costs per patient were significantly lower in office-based setting versus the hospital stay group (431 euros versus 1320). Conclusion: Implementing ambulatory surgery for hemorrhoids is feasible, efficient, safe, and cost-effective but correct selection of patients is necessary

Open Abdomen Management and Candida Infections: A Very Likely Link

Objective. Laparostomy can be applied in trauma, abdominal sepsis, intra-abdominal hypertension, or compartment syndrome. Systemic infections, especially if complicated by Candida, are associated with a high risk of mortality. Methods. This is a single-centre retrospective case series of 47 cases admitted to our Department, which required laparostomy procedure; we analyzed the type of surgery, temporary abdominal closure, duration of open abdomen, complications, SOFA score, mortality with Candida infections, and empirical or targeted antifungal therapy. Results. We found that patients with Candida infection were related with a statistically significant difference () with a complication after OA closure, total complications, time elapsed after OA application, time spent on the first surgical OA application, type of temporary abdominal closure that is used, and duration of the open abdomen. The use of empirical and targeted antifungal therapy is related to the duration of open abdomen too. Conclusions. Management of the OA is often burdened by sepsis or septic shock, especially when complicated by Candida infection. Candida score is a validated tool to identify patients who can be treated empirically, but every situation must be considered on an individual basis

Spontaneous thrombosis of primary external jugular veins aneurysms

External jugular vein (EJV) aneurysms represent a rare condition whose origin, evolution and consequent best therapeutic options still need further investigations. We present herein two peculiar clinical cases. In the first one, an EJV aneurysm developed around a malformed valve which embedded a spontaneous thrombosis. Transverse cutaneous nerve compression by the aneurysmatic mass was identified. In the second case, a recurring thrombosed EJV aneu - rysm was found pinched among the platysma muscle and the superficial layer of the cervical fascia. A pertinent literature review is also presented in order to interpret the findings herein never previously described

The controversy on chronic cerebrospinal venous insufficiency

The objective of this review is to analyze the actual scientific controversy on chronic cerebrospinal venous insufficiency (CCSVI) and its association with both neurodegenerative disorders and multiple sclerosis (MS). We revised all published studies on prevalence of CCSVI in MS patients, including ultrasound and catheter venography series. Furthermore, we take into consideration other publications dealing with the pathophysiologic consequences of CCSVI in the brain, as well as ecent data characterizing the pathology of the venous wall in course of CCSVI. Finally, safety and pilot data on effectiveness of endovascular CCSVI treatment were further updated. Studies of prevalence show a big variability in prevalence of CCSVI in MS patients assessed by established ultrasonographic criteria. This could be related to high operator dependency of ultrasound. However, 12 studies, by the means of more objective catheter venography, show a prevalence >90% of CCSVI in MS. Global hypo-hypoperfusion of the brain, and reduced cerebral spinal fluid dynamics in MS was shown to be related to CCSVI. Postmortem studies and histology corroborate the 2009 International Union of Phlebology (UIP) Consensus decision to insert CCSVI among venous malformations. Finally, safety of balloon angioplasty of the extracranial veins was certainly demonstrated, while prospective data on the potential effectiveness of endovascular treatment of CCSVI support to increase the level of evidence by proceeding with a randomized control trial (RCT). Taking into account the current epidemiological data, including studies on catheter venography, the autoptic findings, and the relationship between CCSVI and both hypo-perfusion and cerebro-spinal fluid flow, we conclude that CCSVI can be definitively inserted among the medical entities. Research is still inconclusive in elucidating the CCSVI role in the pathogenesis of neurological disorders. The controversy between the vascular and the neurological community is due to the great variability in prevalence of CCSVI in MS patients by the means of venous ultrasound assessment. More reproducible and objective CCSVI assessment is warranted. Finally, current RCT may elucidate the role of CCSVI endovascular treatment

Short endovenous laser ablation of the great saphenous vein in a modified CHIVA strategy

Mini-invasiveness, ease of use and execution speed represent the reasons for endovenous laser ablation success. Nevertheless, the strategic choice remains the ablation of the saphenous trunk. Hemodynamic correction (CHIVA) represents an option, based on a saphenous-sparing therapeutic strategy. We tested the feasibility of a modified CHIVA strategy by means of endovenous lasers (EL) shrinkage of segmental great saphenous vein (GSV) tracts, in networks characterized by sapheno-femoral incompetence and re-entry perforators focused on the GSV. We report the follow up of the first 2 chronic venous disease [C1,2,3sEpAsPr1,2,3, venous clinical severity score (VCSS) 8 and 9 respectively] treated cases. At 1-year follow up both patients were C1,2,3sEpAsPr1,2,3 and the VCSS were 1 and 2 respectively. The non-treated GSV tracts maintained their patency. ELs were herein used within a saphenous-sparing therapeutic plan, thanks to an accurate pre-operative hemodynamic assessment, which allowed the shrinkage of only the first saphenous trunk tract only. Proper technical and hemodynamic considerations are discussed

Evaluation on prognostic efficacy of lymph nodes ratio (LNR) and log odds of positive lymph nodes (LODDS) in complicated colon cancer: The first study in emergency surgery

Background: Lymph node involvement is one of the most important prognostic factors in colon cancer. Twelve is considered the minimum number of lymph nodes necessary to retain reliable tumour staging, but several factors can potentially influence the lymph node harvesting. Emergent surgery for complicated colon cancer (perforation, occlusion, bleeding) could represent an obstacle to reach the benchmark of 12 nodes with an accurate lymphadenectomy. So, an efficient classification system of lymphatic involvement is crucial to define the prognosis, the indication to adjuvant therapy and the follow-up. This is the first study with the aim to evaluate the efficacy of lymph nodes ratio (LNR) and log odds of positive lymph nodes (LODDS) in the prognostic assessment of patients who undergo to urgent surgery for complicated colonic cancer. Methods: This is a retrospective study carried out on patients who underwent urgent colonic resection for complicated cancer (occlusion, perforation, bleeding, sepsis). We collected clinical, pathological and follow-up data of 320 patients. Two hundred two patients met the inclusion criteria and were distributed into three groups according to parameter N of TNM, LNR and LODDS. Survival analysis was performed by Kaplan-Meier curves, investigating both overall survival (OS) and disease-free survival (DFS). Results: The median number of harvested lymph nodes was 17. In 78.71% (n = 159) of cases, at least 12 lymph nodes were examined. Regarding OS, significant differences from survival curves emerged for ASA score, surgical indication, tumour grading, T parameter, tumour stage, N parameter, LNR and LODDS. In multivariate analysis, only LODDS was found to be an independent prognostic factor. Concerning DFS, we found significant differences between survival curves of sex, surgical indication, T parameter, tumour stage, N parameter, LNR and LODDS, but none of these confirmed its prognostic power in multivariate analysis. Conclusions: We found that N, LNR and LODDS are all related to 5-year OS and DFS with statistical significance, but only LODDS was found to be an independent prognostic factor for OS in multivariate analysis

A rare diaphragmatic hernia with a delayed presentation of intestinal symptoms following spleno-distal pancreatectomy: a case report

Acquired diaphragmatic hernia, non-related to trauma, is a very rare condition. It can constitute a therapeutic problem and the surgical solution is not always immediately clear. We report the case of a 73-year-old woman with a history of spleno-distal pancreatectomy for a neuroendocrine tumour performed in 2009, who came back to Emergency Room 2 years later, complaining of abdominal pain. Chest radiography and computed tomography were performed; they showed a diaphragmatic hernia with visceral migration into the thorax. The diaphragmatic defect was surgically repaired and the patient had an uneventful post-operative recovery

Do I Need to Operate on That in the Middle of the Night? Development of a Nomogram for the Diagnosis of Severe Acute Cholecystitis

Background Some authors have proposed different predictive factors of severe acute cholecystitis, but generally, the results of risk analyses are expressed as odds ratios, which makes it difficult to apply in the clinical practice of the acute care surgeon. The severe form of acute cholecystitis should include both gangrenous and phlegmonous cholecystitis, due to their severe clinical course, and cholecystectomy should not be delayed. The aim of this study was to create a nomogram to obtain a graphical tool to compute the probability of having a severe acute cholecystitis. Methods This is a retrospective study on 393 patients who underwent emergency cholecystectomy between January 2010 and December 2015 at the Acute Care Surgery Service of the S. Anna University Hospital of Ferrara, Italy. Patients were classified as having a non-severe acute cholecystitis or a severe acute cholecystitis (i.e., gangrenous and phlegmonous) based on the final pathology report. The baseline characteristics, pre-operative signs, and abdominal ultrasound (US) findings were assessed with a stepwise multivariate logistic regression analysis to predict the risk of severe acute cholecystitis, and a nomogram was created. Results Age as a continuous variable, WBC count ≥ 12.4 × 103/μl, CRP ≥9.9 mg/dl, and presence of US thickening of the gallbladder wall were significantly associated with severe acute cholecystitis at final pathology report. A significant interaction between the effect of age and CRP was found. Four risk classes were identified based on the nomogram total points. Conclusions Patients with a nomogram total point ≥ 74 should be considered at high risk of severe acute cholecystitis (at 74 total point, sensitivity = 78.5%; specificity = 78.2%; accuracy = 78.3%) and this finding could be useful for surgical planning once confirmed in a prospective study comparing the risk score stratification and clinical outcomes

Laser-assisted strategy for reflux abolition in a modified CHIVA approach

The aim of this study was to assess feasibility and efficacy of an endovenous laser (EL) assisted saphenous-sparing strategy in chronic venous disease (CVD). Fourteen CVD patients (C2,3,4s Ep As Pr1,2,3) underwent a saphenofemoral junction (SFJ) treatment by EL just from below the superficial epigastric vein downward for a limited tract, together with a flush ligation of the incompetent tributaries of the great saphenous vein (GSV) along the leg. The following GSV parameters were assessed 15 cm below the SFJ: reflux time, caliber, peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI). Venous clinical severity score and the Clinical, Etiological, Anatomical, and Pathophysio logical (CEAP) classification clinical classes were assessed. At 1 year follow up 3 cases were considered failures because of a GSV thrombosis, even if they presented a GSV recanalization with a laminar flow within at the 2 years follow-up. Eleven procedures succeeded because neither minor nor major peri-procedural complications were reported, apart 2 cases of self-healing bruising. In these last 11 cases the procedure led to a GSV reflux suppression (from 3.1±0.4 s to a retrograde laminar draining flow), to a GSV caliber reduction (from 9.4±0.5 to 3.1±0.2 cm, P<0.001), to a PSV reduction (from 50.2±4.6 to 18.4±3.5 cm/s, P<0.001), to a RI reduction (from 0.9±0.2 to 0.51±0.2, P<0.005) and to an oscillatory flow suppression (EDV from -8.9±1.6 to 6.2±2.3 cm/s, P<0.001). Both CEAP and venous clinical severity score improved from 3 to 1 (P<0.001) and from 7±2 to 2±1 (P<0.05), respectively. The GSV flow reappeared below the shrunk tract draining into the re-entry perforator. Sapheno-femoral reflux suppression can be obtained by just a GSV segmental closure. An almost 80% of success rate of the present investigation paves the way for an even wider diffusion of endovenous techniques, moreover erasing the surgical requirements for those who would like to perform a saphenoussparing strategy. In this way new devices could be used inside equally innovative strategies

Do I Need to Operate on That in the Middle of the Night? Development of a Nomogram for the Diagnosis of Severe Acute Cholecystitis

Background Some authors have proposed different predictive factors of severe acute cholecystitis, but generally, the results of risk analyses are expressed as odds ratios, which makes it difficult to apply in the clinical practice of the acute care surgeon. The severe form of acute cholecystitis should include both gangrenous and phlegmonous cholecystitis, due to their severe clinical course, and cholecystectomy should not be delayed. The aim of this study was to create a nomogram to obtain a graphical tool to compute the probability of having a severe acute cholecystitis. Methods This is a retrospective study on 393 patients who underwent emergency cholecystectomy between January 2010 and December 2015 at the Acute Care Surgery Service of the S. Anna University Hospital of Ferrara, Italy. Patients were classified as having a non-severe acute cholecystitis or a severe acute cholecystitis (i.e., gangrenous and phlegmonous) based on the final pathology report. The baseline characteristics, pre-operative signs, and abdominal ultrasound (US) findings were assessed with a stepwise multivariate logistic regression analysis to predict the risk of severe acute cholecystitis, and a nomogram was created. Results Age as a continuous variable, WBC count ≥ 12.4 × 103/μl, CRP ≥9.9 mg/dl, and presence of US thickening of the gallbladder wall were significantly associated with severe acute cholecystitis at final pathology report. A significant interaction between the effect of age and CRP was found. Four risk classes were identified based on the nomogram total points. Conclusions Patients with a nomogram total point ≥ 74 should be considered at high risk of severe acute cholecystitis (at 74 total point, sensitivity = 78.5%; specificity = 78.2%; accuracy = 78.3%) and this finding could be useful for surgical planning once confirmed in a prospective study comparing the risk score stratification and clinical outcomes