Accuracy of computed tomography in staging acute appendicitis and its impact on surgical outcome and strategy: a multi-center retrospective case-control study.

INTRODUCTION: The aims of this study were to evaluate the concordance between AAST-CT appendicitis grading criteria, first published in 2014, and surgical findings and to assess the impact of CT staging on the choice of surgical approach. METHODS: This was a multi-center retrospective case-control study including 232 consecutive patients undergoing surgery for acute appendicitis and who had undergone preoperative CT evaluation between 1 January 2017 and 1 January 2022. Appendicitis severity was classified in 5 grades. For each degree of severity, the surgical outcome between patients undergoing open and surgical approach was compared. RESULTS: An almost perfect agreement (k = 0.96) was found between CT and surgery in staging acute appendicitis. The vast majority of patients with grade 1 and 2 appendicitis underwent laparoscopic surgical approach and showed low morbidity rate. In patients with grade 3 and 4 appendicitis, laparoscopic approach was adopted in 70% of cases and was associated, if compared to open, with a higher prevalence of postoperative abdominal collections (p = 0.05; fisher's exact test) and a significantly lower prevalence of surgical site infections (p = 0.0007; fisher's exact test). All the patients with grade 5 appendicitis were treated by laparotomy. CONCLUSIONS: AAST-CT appendicitis grading system seems to show a relevant prognostic value and a potential impact on the choice of surgical strategy, directing toward a laparoscopic approach in patients with grade 1 and 2, an initial laparoscopic approach, replaceable by the open one, for grade 3 and 4 and an open approach in patients with grade 5.

Hand-Sewn Versus Stapled Small Bowel Anastomoses in Patients With Secondary Mesenteric Ischemia.

INTRODUCTION: Although stapled anastomoses have been widely evaluated in the context of the elective surgery, few reports compared manual with stapled anastomoses in patients undergoing emergency surgery. The aim of this study is to compare the outcome of hand-sewn end-to-end anastomoses with stapled side-to-side and stapled end-to-side anastomoses in patients undergoing small bowel resection for acute mesenteric ischemia secondary to intestinal obstruction. METHODS: From January 2015 to June 2021 all the hemodynamically stable patients undergoing emergency surgery with small bowel resection for intestinal obstruction were enrolled in this study. According to surgical technique in performing anastomosis, the patients were divided into three groups: group 1: hand-sewn end-to-end anastomosis, group 2: stapled end-to-side anastomosis, and group 3: stapled side-to-side anastomosis. RESULTS: Although the anastomosis failure rate was higher in group 3, it was not significantly different between the three groups (P = 0.78: chi-square test). Likewise, no significant differences in the median hospital stay were found between the patients' groups (P = 0.87: Kruskal-Wallis test). The median operating time was similar in patients undergoing stapled anastomoses and was significantly higher in patients undergoing hand-sewn anastomoses (P = 0.0009: Kruskal-Wallis test). CONCLUSIONS: In patients undergoing emergency small bowel resection for complicated intestinal obstruction, a similar outcome in terms of dehiscence rate and hospital stay can be achieved performing stapled or hand-sewn anastomoses, even if restoring the intestinal continuity with stapled technique is associated with lower operating time.

Usefulness of damage control approach in patients with limited acute mesenteric ischemia: a prospective study of 85 patients.

To evaluate the efficacy of the damage control approach by two-step surgical procedure in not critical patients (without sepsis or septic shock) with peritonitis from limited acute mesenteric ischemia. From April 2013 to April 2020, 85 patients [49 (57.7%) women and 36 (42.3%) men, median age 69.5 (range 38-92)] were enrolled in this study and underwent emergency surgery. After resection of ischemic bowel, basing on the individual decision of the single surgeon, the patients underwent primary end-to-end anastomosis (Group 1) or damage control approach (Group 2) including primary laparotomy with resection of ischemic bowel, temporary abdominal closure and a second-look procedure at 48 h with re-evaluation of bowel vitality. Forty-seven (55.3%) patients underwent one-stage surgical treatment and 38 (44.7%) patients received a two-step procedure. In the latter group, at second exploration, 8 (21%) patients required a further intestinal resection, due to mesenteric ischemia progression. Both anastomosis dehiscence rate and need for ileostomy in Group 1 patients were significantly higher than in Group 2 (23.4% vs 5.3%: p = 0.03 and 19.1% vs 2.6%: p = 0.03; Fisher's exact test). No significative differences in mortality and morbidity rate were found between the two groups. The damage control approach by two-step surgical procedure may represent a valid innovative option in the management of not critical patients with limited acute mesenteric ischemia, achieving a better clinical outcome if compared with surgical treatment by one-step procedure.

Impact of SARS-Cov-2 pandemic on Emergency General Surgery. A single-center observational study.

INTRODUCTION: Several articles have been published on impact COVID-19 infection about reduction of surgical activity. We have focused on the differences between our surgical activity in an Emergency General Surgery department in "Cardarelli" Hospital in Naples. METHODS: This retrospective study compared the patients treated from March 9, 2020 to April 27, 2020 (Italian lockdown time) and the patients treated in the same period of 2019. We recruited 75 patients in Group A (2020) and 165 patients in Group B (2019). RESULTS: There was a reduction in hospitalizations for non-trauma disease (69 in group A and 122 in group B with p: 0.001), a reduction in transfers from other hospitals (2 patients in group A and 17 in group B with p. 0.04) and a reduction in hospitalizations for trauma disease (6 in group A and 43 in group B with p: 0.001). The severity of the disease in 2020 was greater than in the same period in 2019 and there was a higher rate of high-grade complications CONCLUSION: From data analysis, we conclude that there has been a reduction in hospitalizations and surgical interventions in our emergency surgery department. The patients, however, had a much more severe disease that resulted in a greater number of complications in the peri and post-operative time. KEY WORDS: COVID-19, Lockdown, Emergency Surgery, Severity of disease.

Treatment of acute diverticulitis with open abdomen technique.

AIM: The aim of this study is to highlight our experience about the use of open Abdomen's technique as strategy for the management of complicated colon diverticulitis with a delayed anastomosis or colostomy. MATERIALS AND METHODS: Thirty patients, with III and IV Hinchey stage, have been undertaken to a surgical procedure with Open Abdomen technique and application of Ab-thera device. A second surgical look was made after 48-72 hours in order to evaluate the possibility to do an anastomosis or colostomy. RESULTS: No deaths in patients with anastomosis were reported, but one case of leakage at the 8th day and one case of micro pulmonary embolism had been displayed. Elderly patients were discharged between the 15TH /18th day. One patient affected by lymphoma was sent in haematology department for other treatment. DISCUSSION: Today trend is to treat the diverticular disease with colic and paracolic abscess by a medical therapy and percutaneous drainage under CT scan or ultrasound view. With III and IV of Hinchey scale we perform the resection with anastomosis or colostomy. The open abdomen technique allows the surgeons to make the decision of colostomy or anastomosis in the second surgical look at 48-72 hours after the first treatment with irrigation and aspiration during AB-Thera. CONCLUSION: The Open Abdomen technique is a valid therapeutic alternative approach for patients with acute diverticulitis disease in III and IV Hinchey grade. This therapeutic approach gives important advantages in patients with delayed colostomy. KEY WORDS: Diverticulitis, Damage Control Surgery, Open Abdomen.

Advantages of Damage Control Strategy With Abdominal Negative Pressure and Instillation in Patients With Diffuse Peritonitis From Perforated Diverticular Disease.

Purpose. To evaluate the results of Damage Control Strategy (DCS) in the treatment of generalized peritonitis from perforated diverticular disease in patients with preoperative severe systemic diseases. Methods. All the patients with diffuse peritonitis (Hinchey 3 and 4) and the American Society of Anesthesiologists (ASA) score ≥3 were included and underwent DCS consisting of a 2-step procedure. The first was peritoneal lavage, perforated colon-stapled resection, and temporary abdominal closure with negative pressure wound therapy combined with instillation. The second step, 48 hours later, included the possibility of restoring intestinal continuity basing on local and general patients' conditions. Results. Thirty patients (18 [60%] women and 12 [40%] men, median age 68.5 [range = 35-84] years) were included (18 [60%] ASA III, 11 [36.7%] ASA IV, and 1 [0.03%] ASA V). Seven patients (23.3%) showed sepsis and 1 (3.33%) septic shock. At second surgery, 24 patients (80%) received a colorectal anastomosis and 6 patients (20%) underwent a Hartmann's procedure. Median hospital stay was 18 days (range = 12-62). Postoperative morbidity rate was 23.3% (7/30) and included 1 anastomotic leak treated with Hartmann's procedure. Consequently, at discharge from hospital, 23 patients (76.6%) were free of stoma. Primary fascial closure was possible in all patients. Conclusions. DCS with temporary abdominal closure by negative pressure wound therapy combined with instillation in patients with diffuse peritonitis from complicated diverticulitis could represent a feasible surgical option both in hemodynamically stable and no stable patients, showing encouraging results including a low stoma rate and an acceptable morbidity rate.

Analysis of the factors influencing the outcome of bleeding of the lower digestive tract. A report of 15 consecutives cases.

The authors present a series of 15 patients with lower gastrointestinal bleeding. 11 (73%) out of 15 patients, were directly subjected to surgery, and 4 (37%) attempted to stop hemorrhage with angiography. In the group of patients undergoing surgery we had a mortality of 1 out of 12 (8%). In the group of patients undergoing embolization, two of four died with 50% of mortality. All patients undergoing surgery had received from a minimum of two to a maximum of four blood bags before surgery. 8 out of 12 patients (67%) received more than two bags. In 10 (67%) out of 15 patients TC scan preoperatively identified the site of bleeding. 10 cases out of 15 patients was evident Anticoagulant or antiplatelet use. In the group of patients undergoing surgical treatment with haemorrhage stopping 60% (6 out of 10) did not take these drugs. No patient had significant alterations to the INR value. Patients undergoing Surgical treatment without haemorrhage stopping had an average age significantly higher than the group with haemorrhage stopping (84 aa vs 54.2). In this group CT scan had identified the source of bleeding in one patient on two (50%) and all patients In the group of deceased patients, the average age was 78 aa, the tac had never identified the site of bleeding, and all had antiaggregates. In the group of deceased patients, the average age was 78 aa, CT scan had never identified the site of bleeding, and all In the group of deceased patients, the average age was 78 aa, the tac had never identified the site of bleeding, and all had antiaggregates KEY WORDS: Lower gastrointestinal bleeding, Prognostic factors, Surgical management.

Unusual bleeding of a giant cell fibroblastoma: a soft tissue sarcoma of the skin mimicking metastatic melanoma.

A 56 year-old man presented to the emergency department after a spontaneous bleeding of a giant mass located on the right axilla. Clinical diagnosis was recurrent hemorrhagic nodular melanoma. Ten months previously a malignant melanoma had been removed from the dorsum by radical excision and surgical margins had been disease-free (MM: Breslow IV, Clark IV, lung and lynphnode metastases). The patient required immediate emergency surgical intervention to prevent death by hemorrhagic shock. The tumor was bleeding and the patient required a transfusion. Subjective symptoms included pain in palpation and spontaneous hemorrhage, poor general appearance, pale skin, BP 80/40 mmHg, HR 100/min with overall symptoms of hypovolemic shock. At the time of surgery, radical tumor excision was performed with an approximately 3 cm circumferential gross tumor free margin. The resultant defect was reconstructed by pectoral rotation fascio-cutaneous flap. The histological diagnosis demonstrated an undifferentiated high-grade pleomorphic sarcoma with microscopic tumor free margins.

[Mesenteric Castleman's disease and inflammatory fibroid polyp of the stomach: a case report and review of the literature]. / Malattia di Castelman mesenterica e polipo fibroide infiammatorio dello stomaco: associazione in un caso clinico e revisione della letteratura.

Castleman's disease is a very rare disease that causes many problems both in diagnosis and therapy. It is often associated with other diseases and can develop in any part of the body. Castleman's disease can be classified as uni-centric or multicentric based on clinical and radiological findings, as hyaline-vascular or plasma-cell based on the histological aspect, and as HIV-related or non-HIV-related, based on the HIV status of the patient. An inflammatory fibroid polyp is a very rare benign lesion that can develop anywhere in the gastrointestinal tract. Such polyps are most commonly found in the gastric antrum and usually occur in 50- to 60-year-old people. The authors report the unusual finding of mesenteric Castleman's disease and an inflammatory fibroid polyp of the stomach in a 41-year-old woman.

Solid-cystic pseudopapillary tumor of pancreas: description of two cases and literature review.

The authors report the cases of two young female patients aged 17 and 27 years who underwent surgery for a rare tumor of the pancreas, Frantz's tumor or solid-cystic pseudopapillary tumor. Solid-cystic pseudopapillary tumor of the pancreas is a rare tumor, accounting for 2.7% of pancreatic exocrine tumors. About 90% of these tumors occur in young women and they can reach very large dimensions. Due to their rareness and behavior, they are often associated with diagnostic and therapeutic problems. In most cases surgical treatment is curative and neither chemotherapy nor radiotherapy should be added. In the few cases where surgery is not possible, radiotherapy can be used because these tumors appear to be radiosensitive.

Laparoscopic procedures for colorectal cancer: analysis of 134 cases.

Laparoscopic procedures to treat colorectal cancer have been increasingly adopted in the last 15 years and seem to be well accepted by the patients. We studied 134 patients treated by laparoscopic colon resection, analysing the reasons for conversion to open laparotomy and outcomes. Over the period from July 2002 to January 2005, 134 patients with different colorectal cancers were treated with a laparoscopic approach in our department. We analysed the conversion rates and reasons for conversion, perioperative complications, hospital stay and recourse to blood transfusions. The laparoscopic procedures led to shorter hospitalisation and a reduction of the blood transfusion requirement, and were well accepted by the patients. The laparoscopic approach for malignant disease of the colon and rectum can improve many aspects of this treatment: Shorter hospitalisation, reduction of blood transfusions and a better quality of life. It also seems to lead to a lower non-specific depression of the immunological response. All these aspects may contribute to better treatment of patients with colorectal cancer. All kinds of laparoscopic colectomy can be performed with oncological criteria but the rate of conversion for rectal cancer is significantly higher (28.6%). In this study the complication rates in the laparoscopic colectomy and converted group were similar.

Spigelian hernia: a rare lateral ventral hernia.

The authors take a treated clinical case as a starting point to consider lateral ventral hernia, generally referred to as "Spigelian hernia". Such hernias are rare (1-2% of all hernias), with a slightly higher incidence in the female sex. Obesity and multiparous status are known to be predisposing factors. Instrumental tests of great importance in terms of specificity and definition such as ultrasonography and computed tomography are available, in cases of diagnostic doubt, for a pathology that in any case has to be detected early in order to avoid possible complications. The treatment is essentially surgical. A personal variant of the surgical repair technique is described with the use of prosthetic material, which guarantees a better result in terms of strength and resistance compared to simple repair surgery.

Outcome of surgical treatment of carcinoma of the pancreas.

AIMS AND BACKGROUND: Pancreatic resections for neoplastic diseases have a high risk of severe intra- and postoperative complications and are associated with high mortality rates. They should be performed as a rule in centers specializing in this type of surgery. However, it is becoming increasingly likely that such tumors may have to be treated in surgery units which are not specifically dedicated to pancreatic surgery. The aim of this study was to assess the improvements in clinical results in a non-specialized general surgery setting in the light of the most recent progress in surgical techniques, drug treatments and nutritional support. METHODS AND STUDY DESIGN: We analyzed 48 patients with pancreatic cancer treated in our institution over the period from 1980 to 1998: 36 had cancer of the head of the pancreas, 5 of the ampulla, 1 in the second duodenal portion, and 6 of the body-tail. The operations performed consisted of 13 Whipple pancreaticoduodenectomies with cutting and stapling of the distal pancreatic stump at the level of the isthmus, 4 left pancreasectomies, 2 local resections of the ampulla, 21 palliative operations, and 2 exploratory laparotomies. RESULTS AND CONCLUSIONS: The patients were submitted to follow-up including clinical examinations, blood-chemistry tests, and instrumental investigations. The mean survival was 18 months in the cases where radical surgery was performed, compared to 11 months after palliative surgery. We conclude that an improved prognosis can obtain after pancreatic resection. This is attributable to a more accurate preoperative staging and to the aid of the various forms of nutritional support and pharmacological prophylaxis currently available.

Topical nifedipine with lidocaine ointment vs. active control for treatment of chronic anal fissure: results of a prospective, randomized, double-blind study.

PURPOSE: Chronic anal fissure may be treated by chemical or surgical sphincterotomy. The aim of this study was to test the efficacy of local application of nifedipine and lidocaine ointment in healing chronic anal fissure. METHODS: The study was performed according to a prospective, randomized, double-blind design. One hundred ten patients who gave informed consent were recruited. They received a clinical examination, a questionnaire to evaluate symptoms and pain, anorectal manometry, and anoscopy. Healing of anal fissure at Day 42 of therapy was defined as the primary efficacy variable of the study. Patients treated with nifedipine (n = 55) used topical 0.3 percent nifedipine and 1.5 percent lidocaine ointment every 12 hours for 6 weeks. The control group (n = 55) received topical 1.5 percent lidocaine and 1 percent hydrocortisone acetate ointment during therapy. Anal pressures were measured by recording resting and maximal voluntary contraction pressures at baseline and at Day 21. Long-term outcomes were determined after a median follow-up of 18 months. RESULTS: Healing of chronic anal fissure was achieved after 6 weeks of therapy in 94.5 percent of the nifedipine-treated patients (P < 0.001) as opposed to 16.4 percent of the controls. Mean anal resting pressure decreased from a mean value +/- standard deviation of 47.2 +/- 14.6 to 42 +/- 12.4 mmHg in the nifedipine group. This represents a mean reduction of 11 percent (P = 0.002). Changes of maximal voluntary contraction in nifedipine-treated patients were not significant. No changes in mean anal resting pressure and maximal voluntary contraction were observed in the control group. We did not observe any systemic side effect in patients treated with nifedipine. After the blinding was removed, recurrence of the fissure was observed in 3 of 52 patients in the nifedipine group within 1 year of treatment, and 2 of these patients healed with an additional course of topical nifedipine and lidocaine ointment. CONCLUSIONS: Our study clearly demonstrates that the therapeutic use of topical nifedipine and lidocaine ointment should be extended to the conservative treatment of chronic anal fissure.

Analysis of factors influencing the diagnostic failure of intraoperative fine needle aspiration cytology in pancreatic cancer.

Intraoperative fine-needle aspiration cytology (IFNAC) of pancreatic lesions provides a safe method of rapid tissue diagnosis. Few studies have included a thorough statistical analysis of the factors influencing the diagnostic failure of IFNAC. IFNAC was performed on 196 patients during surgical procedures for pancreatic and periampullary masses over an 18-year period. The sensitivity was 90.6% and the specificity 100%. There was a 0% puncture-related complication rate. In all, 6 clinicopathological factors were analyzed to elucidate correlations, if any, with IFNAC failure using statistical analysis. Statistical analysis of each of these clinicopathological factor showed that the cases of failure tended to be related to small tumour size (P < 0.0001), well-differentiated grading (P < 0.002) and a nuclear size similar to the surrounding RBCs (P < 0.0001). Age, gender, moderately or poorly differentiated tumours, and multiple punctures proved to be of no statistical significance in our analysis. We suggest that diagnostic failure of IFNAC seems to be caused mainly by a structural factor such as tumour size and an intrinsic one (a cellular low atypism factor such as well-differentiated grading and small nuclear size). However, we would caution that negative IFNAC cannot be relied on to definitively exclude a diagnosis of carcinoma and, in many instances, the justification for pancreatic resection cannot always be based on cytologic findings, but rather on clinical and laparotomy findings.

[Peritoneal multicystic mesothelioma: unusual case of localization in the left lobe of the liver]. / Mesotelioma multicistico del peritoneo: un caso insolito localizzato al lobo sinistro del fegato.

Peritoneal multicystic mesothelioma is a very rare clinical condition. This neoplastic variant has a high incidence of recurrence after surgical resection. It usually occurs in middle-aged women with a previous history of gynaecological surgery and presents with the symptoms of an abdominal or pelvic mass. The case reported here is that of a 58-year-old woman, characterised first by a left liver-lobe tumour and then by a subsequent episode of emission of cystic matter from an abdominal fistula. The relevant literature is reviewed and the clinical aspects and treatment of this disease are discussed.