Acute acalculous cholecystitis on a COVID-19 patient: a case report.

INTRODUCTION: We report an extremely rare case of acute acalculous cholecystitis on a COVID-19 patient. In our knowledge, this is the first report of laparoscopic cholecystectomy performed on a COVID-19 patient. PRESENTATION OF CASE: A COVID-19 patient was diagnosed with acute acalculous cholecystitis and a multidisciplinary team decided to perform a percutaneous transhepatic biliary drainage (PTBD) as the first treatment. SARS-CoV-2 RNA was not found in the bile fluid. Because of deterioration of the patient's clinical conditions, laparoscopic cholecystectomy had to be performed and since the gallbladder was gangrenous, the severe inflammation made surgery difficult to perform. DISCUSSION: Acalculous cholecystitis was related with mechanical ventilation and prolonged total parenteral nutrition, in this case the gangrenous histopathology pattern and the gallbladder wall ischemia was probably caused by vascular insufficiency secondary to severe acute respiratory distress syndrome of COVID-19 pneumonia. The percutaneous transhepatic gallbladder drainage (PTBD) was performed according to Tokyo Guidelines because of high surgical risk. Laparoscopic cholecystectomy was next performed due to no clinical improvement. The absence of viral RNA in the bile highlights that SARS-CoV-2 is not eliminated with the bile while it probably infects small intestinal enterocytes which is responsible of gastrointestinal symptoms such as anorexia, nausea, vomiting, and diarrhoea. CONCLUSIONS: Although the lack of evidence and guidelines about the management of patient with acute cholecystitis during COVID-19 pandemic, laparoscopic cholecystectomy, at most preceded by PTGBD on high surgical risk patients, remains the gold standard for the treatment of acute cholecystitis on COVID-19 patients.

Evaluation of amotosalem treated platelets over 7 days of storage with an automated cytometry assay panel.

INTRODUCTION: Pathogen Inactivation allows to overcome microbial contamination and growth related to storage of platelets concentrates (PC) at room temperature. The aim of our study was to evaluate the platelet storage lesion extending the storage period of pathogen inactivated platelet concentrates over 7 days using an automated cytometry assay panel. METHODS: We analyzed 43 concentrates subjected to pathogen inactivation (CPPI) at 3, 5 and 7 days evaluating: platelet count, mean platelet volume, platelets at low optical density, platelets at high density, GPIIb-IIIa glycoprotein, platelet microparticles, lactate dehydrogenase. The collection bags (Fenwal) and the IBS kit made in PL2410/PL2411 are approved for the conservation of PC up to 7 days. Data analysis was performed with anova test. RESULTS: All the parameters except small platelets and PMP were statistically different among day 7 vs. 3 and day 7 vs. 5. CONCLUSIONS: Our study showed a progressive modification of pathogen inactivated platelet concentrates observed up to 7 days. The persistence of the secretory pool and the presence of the platelet membrane fibrinogen receptor suggest the persistence of a potential hemostatic efficacy. Clinical studies are necessary to directly correlate this type of analysis to 24 h recovery or survival of transfused platelets in humans.

[Ileal invaginations caused by Peutz-Jeghers polyposis]. / Invaginazioni ileali da poliposi di Peutz-Jeghers.

The Peutz-Jeghers syndrome is considered a familial polyposis syndrome. The polyps are of hamartomatous type. The symptomatology is due to the more voluminous polyps which can necrotize, ulcerate, bleed and cause intussusception and intestinal obstruction. A case of ileum-ileal intussusception due to Peutz-Jeghers syndrome is reported. The utility of a genealogic research is underlined and the recent results of the genetic research are evaluated. The surgical therapy of Peutz-Jeghers syndrome can have many aims: 1) to remove all big polyps, 2) to avoid the danger of canceration, 3) to prevent the hemorrhagic or occlusive risks and complications.

[Early gastric cancer. The therapeutic options]. / Early gastric cancer. Opzioni terapeutiche.

The best therapeutic treatments for early gastric cancer are evaluated. Due to the difficulty of preoperative and intraoperative staging, it's reasonable to consider early gastric cancer as a composite disease; while some mucous localizations can benefit of minor therapeutic treatments, the submucous cancer must be treated as the parietal gastric cancer.

[Primary lymphoma of the small intestine. A clinical case report and review of the literature]. / Il linfoma primitivo dell'intestino tenue. Descrizione di un caso clinico e revisione della letteratura.

The authors present a case of small bowel primitive lymphoma found in a 66-years-old female. After having briefly reviewed the literature they direct their attention to the clinical-instrumental diagnostic difficulties of this neoplasm which is often discovered only when it has already invaded various organs. Therefore surgical therapy is not always radical. This fact in addition to the fatally rapid postoperative course led the authors to discuss the problems involved in a correct treatment of this pathology.

[Ileal and axillary metastasis of primary unknown site melanoma. Clinical case]. / Metastasi ileale ed ascellare da melanoma primitivo a sede ignota. Caso clinico.

The incidence of Cutaneous Melanoma is 4-5% of all the tumors of the skin. This incidence increases several folds in the last years. Metastases of Melanoma involve lungs, skin, soft tissue, liver, bone, brain, but in 20-30% of the patients involve gastrointestinal (GI) tract. In 60-70% of the cases GI metastases involve small bowel, in 15-20% stomach, in 10-20% large bowel, in 5% esophagus. In 8% of the patients the primary cutaneous melanoma is not known. The prognosis of the patients with metastatic melanoma is poor with an average survival of 5 months. One patient male, 51 years old, underwent surgery for metastases from melanoma in the lymph nodes of the right axilla and in the gastrointestinal tract (ileum). An ileo-ileo anastomosis and a lymphoadenectomy of the nodes of the right axilla were performed. After a first chemotherapy with DTIC (800 mg/m2) + a-IFN(3MU three times every week) and another with CDDP (30 mg/m2 day 1-3), DTIC (250 mg/m2 day 1-3) and VDS (2.5 mg/m2 day 1) with no response, the patient was treated with chemo-immunotherapy sec. Bernengo, slightly modified: CDDP 75 mg/m2; IL-2 18 MU (9MU b.d.) day 3-6 and 17-21; a-IFN 5MU three times every week. This therapy had a partial response of short-course (three months) and the patient died 15 months after surgery. The authors hope that immunotherapy and genetic therapy improve the survival of the patients with metastatic melanoma in the next years.

[Low ileorectal anastomosis in the surgery of ulcerative rectocolitis]. / L'ileorettoanastomosi bassa nella chirurgia della rettocolite ulcerosa.

The authors report their experience of 23 patients with ulcerative colitis treated with surgery from 1991 to 1994. At admission 8 patients had a high-grade illness, 10 patients had a middle-grade illness, 5 patients had a toxic megacolon. All the patients were treated with systemic medical management (mesalazine + methylprednisolone) and topical medical management with rectal steroid (methylprednisolone) and rectal mesalazine by enema, and with nutritional support (Total Parenteral Nutrition). The 5 patients with toxic megacolon, after 48 hours of unsuccessful medical management, underwent surgery with deferred urgency; the other 18 patients underwent surgery after one-four months. The authors prefer the ileorectal anastomosis (IRA), since the rectal lesions are more susceptible to topical therapy. A single-stage IRA was performed in 17 patients. A sigmoid resection has been employed in the first stage in the 18th patient with a local development of the disease in the sigma; a following relapse of the lesions required a total colectomy with a low ileorectal anastomosis. A first-stage subtotal colectomy with ileostomy and Hartmann closure of the rectum with low ileorectal anastomosis at a later date was performed in the 5 patients with toxic megacolon. One of these, 18 years old, died after a heart failure. After surgery, as soon as the patients start moving their bowels all of these had again a systemic therapy with mesalazine for a short period and after they had a topical therapy with mesalazine + methylprednisolone by enema, for a long period. The average postoperative period of admission was 16.3 days. The functional results have been encouraging with an average of 1.6 bowel movements daily and an average of 0.4 nocturnal bowel movements. All the patients had a normal anal sphincter function with an acceptable stool frequency. In male patients there no urinary or sexual defects. In one case of these, there was a low grade of dysplasia, revealed by endoscopic biopsy. The authors conclude that today surgical treatment of ulcerative colitis is not well established.

[The laparoscopic approach to the polycystic liver and adnexal cysts]. / Approccio laparoscopico alla policistosi epatica e alle cisti annessiali.

Having re-examined the nosographic data acquired on the subject of hepatic polycystosis and uterine adnexal cysts, the authors report the results of their experience. On the basis of the evaluation of these results (no laparotomic conversion, no postoperative complications, reduced hospital stay), which are comparable to those reported in the literature, the authors conclude that the modern technology may be used to advantage in all cases where laparoscopic surgery is not difficult, does not require numerous tests and does not entail a high risk of complications.

[Heredity and colorectal cancer]. / Familiarità e cancro colorettale.

The authors underline the role of inheritance in colorectal cancer and reporting the genealogical study of two families with high incidence of colorectal cancers personally observed. They thought that the genetic endowment (oncogenes, suppressor genes, microsatellite instability, protein-kinase C) was implicated directly in the genesis of disease.

[The utility of isolating the recurrent nerve and parathyroids in the prevention of complications in thyroid surgery. The role of the superior laryngeal nerve and C cells]. / Utilità dell'isolamento del nervo ricorrente e delle paratiroidi nella prevenzione delle complicanze in chirurgia tiroidea. Il ruolo del laringeo superiore e delle cellule C.

The authors emphasize systematic isolation of the recurrent nerve and of the parathyroids, to prevent complications in surgery of the thyroid. Moreover they try to underline the significance of the superior laryngeal nerve and the role of parafollicular cells (today unknown) for a rational and modern therapy of the non-neoplastic diseases of the thyroid.

[Peritoneal mesothelioma. A case report]. / Il mesotelioma peritoneale. Caso clinico.

Peritoneal mesothelioma is a rare neoplasm (annual incidence: 1-2 cases per million in the general population) and forms about 10% of all mesotheliomas. The authors report a case of malignant mesothelioma of the peritoneum in a male, 61 years old. After laparotomy the patient was treated with intraperitoneal administration of cisplatin (40 mg/m2 day 1-2-3-29-30-31) and intravenous administration of mitomycin C (10 mg/m2 day 1). The renal toxicity was avoided with the GSH and with prehydration before and after administration of the cisplatin. The bone marrow toxicity was avoided with the subcutaneous administration of G-CSF (300 mg three times each week) and erythropoietin (10.000 U three times a week). After the first cycle, with the reduction of the ascites, the cisplatin was administered intravenously too. After six cycles of chemotherapy (18 months after laparotomy) the patient is alive and he has a performance status of 1 (ECOG/WHO). The chemotherapy with cisplatin and mitomycin C must be preferred to the anthracycline in all the patient with cardiologic involvement. The cisplatin administered by intracavitary route give a quick response with less systemic toxicity. A review of the literature confirms the rarity of this pathology, linked epidemiologically with exposure to asbestos, and the difficulty of the preoperative diagnosis: in fact cytologic assay and ultrasonographic and TC scan always don't permit to discover a mesothelioma. The laparotomy and the laparoscopy are useful in the P.M. for the possibility of the biopsies and the apposition of the catheters for intracavitary therapy. The response of peritoneal mesothelioma to treatment is poor. The median survival after the appearance of the symptom is less than 18 months.

[Preliminary results of a bacteriologic and immunologic study in patients subjected to colorectal surgery]. / Risultati preliminari di uno studio batteriologico e immunologico in pazienti sottoposti a chirurgia retto-colica.

This study examines patients undergoing colorectal surgery for carcinoma, bacteriological data in faecal and systemic immunological data; these patients before surgery received short-term chemoprophylaxis with ceftriaxone (2 g e.v.) and thymopentina (1 phial/day for 15 days) and after surgery thymopentina (1 phial for three time a week). With these data the authors try to create immunomodulation and antibiotic chemoprophylaxis protocol for the reduction of the septic complications due to intestinal bacterial flora and immunological defence reduction.

Effect of a broad-spectrum cephalosporin on the oral and intestinal microflora in patients undergoing colorectal surgery.

The influence of ceftriaxone on oral and intestinal flora was investigated in 10 patients undergoing colorectal surgery. Ceftriaxone was given intravenously in one 2g dose before anesthesia. Saliva and feces samples were collected and analyzed on day 0, 3, 5, 14 and 28 after drug administration. All specimens were cultured quantitatively for aerobic and anaerobic microorganisms; representative colonies of each morphologic type of organism cultured were identified. The oral aerobic flora was somewhat affected by the administration of ceftriaxone. In all patients the number of Streptococci, Staphylococci and Neisseria decreased during the 5 days after ceftriaxone administration. No significant changes in the number of anaerobic commensal occurred. The oral microflora of all patients after 14 days had returned to normal. The aerobic fecal flora was considerably affected: in all patients enterobacteria were eliminated or strongly suppressed. Only minor changes in the number of aerobic gram-positive bacteria were observed, and the anaerobic intestinal flora showed only minor alterations. On day 28 the intestinal flora were normalized in all respects. No new colonizing microorganisms were isolated during the investigation period and no colonization with ceftriaxone-resistant bacteria was observed. No postoperative infection occurred and no adverse effects were registered.

[Surgical chemoprophylaxis with ceftriaxone]. / Chemioprofilassi chirurgica con ceftriaxone.

UNLABELLED: Ceftriaxone is a cephalosporin of third generation. It is characterized by a broad spectrum, a long half-life and a good capacity of diffusion in tissue. We have studied 67 patients. Age ratio was 44 years. 25 patients did not receive short term prophylaxis; 42 patients did (2 gr iv of ceftriaxone one hour before the operation). In clean surgery, only patients immunodepressed or malnourished received chemoprophylaxis. Patients who received 2 gr iv of ceftriaxone one hour before incision, received antibiotic therapy only on the appearance of septic complications. RESULTS: two patients submitted to chemoprophylaxis (4.8%) showed complications (cystitis and bronchial pneumonia). In the control group antibiotic therapy was undertaken only if septic complication appeared. 19 patients (76%) did not showed any complications. 6 patients (24%) showed surgical wound infection, acute pharyngo-tracheitis, cystitis. Finally, wound infections were limited exclusively to the control group. The ratio of respiratory infections was not statistically significant in the two groups; cystitis resulted more frequent in the control group than in the prophylaxis group. Prophylaxis with 2 gr single dose of ceftriaxone intravenously is effective in reducing the influence of infective complications in clean/contaminated surgery and clean risk surgery.

[Staplers in surgery: state of the art]. / Le suturatrici meccaniche in chirurgia: stato dell'arte.

After a review of the technical development and application of staplers from their introduction to the present day, the indications to the use of this instrument in all gastroenterological areas from the oesophagus to the rectum as well as in chest, gynaecological and urological surgery specified. The advantages offered by staplers in the creation of intestinal anastomoses are undeniable, but these instruments must be considered alternatives to traditional surgery, the techniques of which should be well known to all surgeons. In certain areas (gastric, ileal and colonic resections etc.), the now widespread return to single thread manual stitches sheds a new light on staplers and reflects the fact that an anastomosis can be performed just as quickly by hand but will be softer and less rigid than a stapled one. It is only in oesophageal and lower rectal surgery that staplers offer a significant advantage, solving problems where hand suturing cannot.