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)

Multimodality approach to malignant pleural mesothelioma: a case report

Introduction: We report a case of diffuse malignant pleural mesothelioma (DMPM) in a 68 years old male patient who was admitted for right sited pleural effusion. The patient was treated by multimodality approach consisting in surgical treatment with Extrapleural Pleuropneumonectomy followed by chemotherapy with Cisplatin and Pemetrexed. He had a disease free period of one year and survived for 31 months. Case report: The patient was admitted to our Institute for a right sited pleural effusion diagnosed on chest X ray. Anamnesis revealed professional asbestos exposure and the patient presented dyspnea, dry cough, right sited chest pain, low fever and loss of weight. As thoracentesis and CT scan did not reveal pathological findings except of the effusion, we performed videothoracoscopy. Several grey nodular lesions involving the costal, diaphragmatic and mediastinic parietal pleural sheets were found. Histological examination of the specimens extracted revealed the presence of epithelial malignant pleural mesothelioma with sarcomatoid areas. Further examinations staged the lesion as Butchart I. Extrapleural pleuropneumonectomy was performed followed by a chemiotherapic treatment with Cisplatin and Pemetrexed. The patient underwent a follow up program with CT scan every four months. The disease free period was of about one year and the patient died after 31 months from diagnosis for septic complications related to chronic effusion. Discussion: Single treatments do not demonstrate an acceptable efficacy on the treatment of DMPM. Multimodality therapy provides good survival improvement and acceptable quality of life for the patients

The Treatment of faecal incontinence following ileostomy takedown after rectal surgery for cancer

Aim. The aim of this study was to assess the effectiveness of rehabilitative treatment of the pelvic floor on faecal incontinence after ileostomy take-down. Background. Several conditions can induce surgeons to fashion an excluding ileostomy. In our experience 40% of patients subjected to ileostomy takedown refer faecal incontinence which becomes a chronic condition if not treated. Design. Between 2006 and 2008 we observed fourteen patients with faecal incontinence after ileostomy takedown. Previous manometric assessment of the pelvic floor functionality they underwent rehabilitative treatment by electrostimulation of the anal sphincter. Methods. The rehabilitation program was organised in 10 sessions each of 15 minutes. In each session a double electrode probe was introduced through the anus which is able to conduct electric impulses at a frequency of 75 Hz with an intensity of 15–50 mA and duration of 150 μs. Results. All patients showed important clinical and manometric improvement. Three patients needed a second rehabilitative treatment with subsequent clinical resolution of faecal incontinence. Conclusions. Improvement in all patients was found although the data are not statistically significant. Consideration of social and psychological implications of treatments is important. Patients need to acquire full control of their body and its functions. Considering that faecal incontinence is a pathology with high social costs it appears necessary to establish an effective and repeatable method of treatment. Electric stimulation seems to be the most adequate tool for this purpose. Relevance to clinical practice. The standardisation of parameters in the treatment protocol of incontinence could allow to extend this therapy to a lot of colo-proctological units

Ruolo della mediastinoscopia e della video toracoscopia per la diagnosi e la stadiazione delle patologie neoplastiche toraco-mediastiniche

Con il presente lavoro si è voluto valutare il ruolo attuale e le prospettive future della diagnostica invasiva chirurgica, intesa come mediastinoscopia e video-toracoscopia nelle lesioni “sospette” del polmone, nella stadiazione delle neoplasie polmonari e nel trattamento delle lesioni secondarie del polmone. È stata compiuta un’analisi retrospettiva delle mediastinoscopie e delle video-toracoscopie effettuate, a solo scopo diagnostico, dal novembre 1997 all’ottobre 2007; la casistica in esame comprende 72 pazienti di cui 55 di sesso maschile e 17 di sesso femminile. Il range d’età è compreso tra 14 ed 82 anni: 1479 per le donne (con una media di 57,2 anni), 29-82 per gli uomini (con una media di 59,4 anni). La mediastinoscopia è risultata diagnostica nel 95% dei casi, nell’unico caso in cui non risultò essere diagnostica fu comunque effettuata una VTS che fu dirimente. La video-toracoscopia ha consentito di porre diagnosi nel 98,1% dei casi, ovvero si è registrato un solo fallimento. Questo caso, in particolare, fu l’unico in cui l’intervento sia stato convertito da toracoscopico ad “open” tuttavia non fu comunque possibile ottenere una diagnosi. Possiamo affermare di aver evitato, in questi 10 anni, grazie all’adeguata indicazione agli interventi di video-toracoscopia e mediastinoscopia circa l’80% (58 casi) di toracotomie inutili su lesioni espansive toraco- mediastiniche. L’esplorazione chirurgica mininvasiva del mediastino e del torace, è in grado di fornire tutte le informazioni necessarie alla corretta programmazione terapeutica, riducendo significativamente, rispetto alla toracotomia, il trauma chirurgico parietale, il dolore post-operatorio e la durata della degenza nei pazienti non candidati all’intervento radicale

Indications to laparoscopic cholecystectomy

The diffuse ultrasound examination for various abdominal diseases increased in the last decades the diagnosis of asymptomatic gallbladder diseases. High-quality data demonstrate that the majority of patients with asymptomatic gallstones will remain asymptomatic (only 2–4 % will develop symptoms annually) and that the complication rate in asymptomatic patients ranges from 0.3 to 3 % per year. Given the low incidence of symptoms development and complication rate per year in nontreated patients, prophylactic laparoscopic cholecystectomy is currently not recommended as standard treatment. N evertheless, according to the conclusion of 2009 Cochrane Review on LC in silent stones, there is no RCT or high-level studies which offer scientifi c evidence to refuse LC to asymptomatic gallbladder stone patients. There is no evidence to recommend prophylactic LC in asymptomatic gallbladder stone patients neither for diabetics, patients on long-term somatostatin, nor patients with porcelain gallbladder in Western countries. Also in patients with gallbladder stones >3 cm, there is not enough data available to recommend prophylactic LC to prevent gallbladder cancer. Nevertheless, recent data suggest that selective prophylactic LC is advisable in some subgroup of patients. Microcalculi and bile sludge in conjunction with a functioning gallbladder are more likely to predispose patients to calculi migration and subsequent onset of choledocholithiasis and acute pancreatitis. Incidental diagnosis of cholelithiasis in preoperative or intraoperative setting for other medical conditions can be treated laparoscopically in the same session if it does not add any risk of conversion and no prosthetic material is being used. A s the risk of sickling, in patients suffering from sickle cell anemia, is reduced by a laparoscopic approach, it should be the fi rst choice. Some ethnic groups and inhabitants of certain geographical areas are more likely to develop gallbladder cancer. Also specifi c ultrasound fi ndings, like selective mucosal calcifi cations, increase the risk of gallbladder cancer. These patients could benefi t from prophylactic LC. C ardiac-transplanted patients with asymptomatic cholelithiasis should undergo LC

Difficulties in the preoperative assessment of pancreatic cystic lesions: a case report

Introduction: Conventional diagnostic instruments encounter great difficulties in the preoperative assessment of pancreatic lesions. Also preoperative histological diagnosis is not trustworthy as there is a high rate of false negatives and differential diagnosis can often fail. Case Report: We report a case of a young woman with instrumental diagnosis of a suspect malignant pancreatic cystic lesion. The patient underwent distal splenopancreasectomy and histological examination of the specimen revealed an Intraductal Papillary Mucinous Neoplasm (IPMN) associated to a Mucinous Cystic Neoplasm (MCN) and an unexpected small neuroendocrine tumor in the pancreatic tail. Discussion: Not all pancreatic neoplasms need a radical surgical treatment which is associated to high morbidity and mortality rates. Nevertheless it is indicated in all cases of MCN with signs of malignant transformation, in main- and branch duct IPMN and in case of pancreatic neuroendocrine tumors if they are singular and in M0 stage. So a certain preoperative histological diagnosis would be desirable. Conclusions: A preoperative definite histological diagnosis, in case of cystic and neuroendocrine neoplasms of the pancreas, is often not feasible. So many patients undergo surgery with the suspect of pancreatic neoplasm as the certain histological diagnosis can only be made on the specimen

Management chirurgico di voluminoso paraganglioma dell’addome: case report e revisione della letteratura

A 58 years old woman was admitted to our Institution with acute endocrine impairment and simulatneous intestinal necrosis resulting from the mass effect of the tumor on the mesenteric vessels. Clinical and biochemical preoperative work up posed the suspect of paraganglioma. Previous intensive care tratment, the patient, underwent surgical resection of the tumor and left hemicolectoly, with immediate remission of both endocrine and abdominal syndromes. Histological examination con firm the preoperative clinical hypothesis. Paragangliomas are rare tumors of the extra-adrenal chromaffin tissue. A paraganglioma may be discovered in the absence of any sympton. When symptomatic, the clinical findings are related to the hypersecretion of catecholamines or to the compression of several anatomical structures from a growing mass. Combined acute syndromes of hormonal impairment and contemporaneous mass effect, as in our case, are exceptional. The diagnosis of the secreting forms may be obtained on the basis of biochemical dosage of serum and urinary catecholamines and metanephrines. The assessment of malignancy for paragangliomas is not always feasible. Several imaging, cytological and hystological parameters have been proposed as predictors of malignancy, but the only element widely accepted is the existence of distant metastais. Surgery represents the tratment of choice for paragangliomas. Benign forms, catecholamine secreting forms and tunors compressing neighbouring anatomical structures can be treated surgically with success. In general, an accurante follow-up after complete resection must be considered

Evaluation of urinary and sexual function in male patients after anterior resection of the rectum (ARR) for rectal cancer

Male sexual and urinary dysfunctions after ARR are important complications. Total mesorectal excision (TMX) with autonomic nerve-sparing technique has been introduced in order to avoid such complications, preserving oncologic radicality. The aim of this study was to assess safeness of this technique in terms of sexual, urinary and voiding function

Le Sequele funzionali dopo chirurgia del retto basso

INTRODUCTION: The treatment of colorectal cancer has changed radically in the last decades. Due to the great advances it is now often possible to subject patients to oncological radical treatments without applying to highly aggressive surgery, such as the Miles abdomino perineal resection, which requires a definitive colostomy. So nowadays we more and more apply to anterior resection of the rectum. Some recent studies about quality of life in patients who underwent anterior resection of the rectum focalized their attention on postoperative functional sequels. In particular incontinence, constipation, obstructed defecation and urgency are some of the symptoms which define the anterior resection syndrome, which can be efficiently treated by electrostimulation and biofeedback. MATERIALS AND METHODS: A prospective study on 61 patients who underwent between 2002 and 2007 anterior resection of the rectum with total mesorectal excision for adenocarcinoma, has shown symptoms of anterior resection syndrome in 14 patients. Succeeding treatment with sphincter electrostimulation and biofeedback has shown improvement in all patients and complete resolution of the anterior resection syndrome in 10 patients who showed a great compliance and a steady improvement on quality of life. DISCUSSION AND CONCLUSIONS: Rehabilitative treatment with electrostimulation and biofeedback can sensibly reduce symptoms of anterior resection syndrome. An accurate manometric functional assessment is necessary before starting treatment with electrostimulation and biofeedback

The Utilization of transanal endoscopic microsurgery (TEM) in the treatment of rectal neoplasms: our experience

TEM is nowadays indicated as radical surgical treatment for benign neoplastic lesions of the subperitoneal rectum which are not endoscopically removable. It is also indicated in the treatment of malign neoplasms in case of in situ adenocarcinomas (ADK) or "early colorectal cancer"