Incidence and predictors of textbook outcome after simultaneous liver and rectal surgeries for Stage IV rectal cancer.

AIM: Textbook outcome (TO) is a new surgical quality measure that combines structure, process and surgical outcomes into a single element. Our study aimed to determine the incidence of TO after simultaneous rectal and liver surgery and to use the achievement of TO as a tool to identify the best candidates for these complex procedures. METHODS: In total, 256 patients who underwent simultaneous liver and rectal surgery for Stage IV rectal cancer between January 2004 and August 2019 at five tertiary centres were enrolled. TO was defined as a lack of complication, prolonged length of stay, readmission and death. RESULTS: Mortality rate at 90 days and major morbidity rate were 2.3% and 15.6%, respectively. An overall TO was achieved in 59% of the patients, which is associated with significantly improved overall (median TO 86.3 months vs. no TO 37.4 months) and disease-free (median TO 70.6 months vs. no TO 24.9 months) survival. On multivariate analysis the presence of multi-comorbidities (OR 3.073) was associated with a reduced likelihood of achieving TO. Left lateral sectionectomy/limited resection was a protective factor (OR 0.416). CONCLUSION: TO was achieved in six of 10 patients undergoing simultaneous resections for rectal cancer and liver metastases. Achieving a TO is strongly associated with improved long-term survival. The best candidates for these procedures were patients without multiple comorbidities and those treated with left lateral sectionectomy/limited resection.

Contribution of Active Iron Uptake to Acinetobacter baumannii Pathogenicity.

Acinetobacter baumannii is an important nosocomial pathogen. Mechanisms that allow A. baumannii to cause human infection are still poorly understood. Iron is an essential nutrient for bacterial growth in vivo, and the multiplicity of iron uptake systems in A. baumannii suggests that iron acquisition contributes to the ability of A. baumannii to cause infection. In Gram-negative bacteria, active transport of ferrisiderophores and heme relies on the conserved TonB-ExbB-ExbD energy-transducing complex, while active uptake of ferrous iron is mediated by the Feo system. The A. baumannii genome invariably contains three tonB genes (tonB1, tonB2, and tonB3), whose role in iron uptake is poorly understood. Here, we generated A. baumannii mutants with knockout mutations in the feo and/or tonB gene. We report that tonB3 is essential for A. baumannii growth under iron-limiting conditions, whereas tonB1, tonB2, and feoB appear to be dispensable for ferric iron uptake. tonB3 deletion resulted in reduced intracellular iron content despite siderophore overproduction, supporting a key role of TonB3 in iron uptake. In contrast to the case for tonB1 and tonB2, the promoters of tonB3 and feo contain functional Fur boxes and are upregulated in iron-poor media. Both TonB3 and Feo systems are required for growth in complement-free human serum and contribute to resistance to the bactericidal activity of normal human serum, but only TonB3 appears to be essential for virulence in insect and mouse models of infection. Our findings highlight a central role of the TonB3 system for A. baumannii pathogenicity. Hence, TonB3 represents a promising target for novel antibacterial therapies and for the generation of attenuated vaccine strains.

Cannabidiol in the acute phase of febrile infection-related epilepsy syndrome (FIRES).

Febrile infection-related epilepsy syndrome (FIRES) is a prolonged refractory status epilepticus (SE) that develops among healthy individuals after a febrile infection. FIRES treatment is challenging due to its poor response to antiseizure medications (ASMs) and anesthetic drugs. The use of cannabidiol (CBD) as an adjunctive treatment has been suggested, albeit data about its role in the acute phase is lacking. This report describes the use of purified CBD in the acute phase of two pediatric cases of FIRES and their long-term outcome. Both children were treated with several ASMs, immunomodulators, anesthetics, and nonpharmacological treatment (ketogenic diet). CBD was administered, as an adjunctive treatment, through nasogastric tube about 30 days after onset. SE resolved within 3 days of reaching the target dose and both were seizure-free for 1 year after. Although it is difficult to define the extent to which each previous therapy contributed to recovery, in both cases CBD therapy was a turning point, reinforcing its potential role as add-on treatment in the acute phase of FIRES.

Status epilepticus as a main manifestation of posterior reversible encephalopathy syndrome after pediatric hematopoietic stem cell transplantation.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a severe neurological complication after pediatric allogeneic hematopoietic stem cell transplantation (allo-HSCT). Seizures are a common manifestation of PRES. Status epilepticus (SE) is a potentially life-threatening event rarely described in this condition. The aim of this study was to describe the clinical and electroencephalographic features of SE as a manifestation of PRES in children after allo-HSCT. PROCEDURE: We retrospectively identified episodes of SE as a consequence of PRES out of 211 children who received allo-HSCT in the period January 2000 to June 2008. RESULTS: PRES was diagnosed in 11 patients. We identified 12 episodes of SE associated to PRES in 10 patients. Nonconvulsive SE (NCSE) involving posterior regions of the brain (confirmed by EEG monitoring) was observed in four cases; convulsive SE (CSE) was observed in eight cases. Gaze deviation, oculoclonic movements, nystagmus, and altered mental status were the main clinical signs during NCSE and preceded CSE in 5/8 cases. Most patients needed intensive care management. A complete normalization of neurological examination and EEG pattern was observed in all patients after SE and withdrawal of causative agent. Follow-up MRI showed complete resolution of brain edema in all patients. CONCLUSIONS: Our experience shows that SE is more frequent than previously reported and is often the main manifestation of PRES after pediatric allo-HSCT. Looking for suggestive clinical signs as well as routine use of EEG monitoring may allow prompt recognition of SE and therapy of both SE and PRES.

Early vagus nerve stimulator implantation as a main predictor of positive outcome in pediatric patients with epileptic encephalopathy.

We describe a multicenter experience with VNS implantation in pediatric patients with epileptic encephalopathy. Our goal was to assess VNS efficacy and identify potential predictors of favorable outcome. This was a retrospective study. Inclusion criteria were: ≤18 years at the time of VNS implantation and at least one year of follow-up. All patients were non-candidates for excisional procedures. Favorable clinical outcome and effective VNS therapy were defined as seizure reduction >50%. Outcome data were reviewed at one, two, three and five years after VNS implantation. Fisher's exact test, Kaplan-Meier and multiple logistic regression analysis were employed. Twenty-seven patients met inclusion criteria. Responder rate (seizure frequency reduction ≥ 50%) at one-year follow-up was 25.9%, and 15.3% at last follow-up visit. The only variable significantly predicting favorable outcome was time to VNS implantation, with the best outcome achieved when VNS implantation was performed within five years of seizure onset (overall response rate of 83.3% at one year of follow-up and 100% at five years). In total, 63% of patients evidenced improved QOL at last follow-up visit. Only one patient exited the study due to an adverse event at two years from implantation. Early VNS implantation within five years of seizure onset was the only predictor of favorable clinical outcome in pediatric patients with epileptic encephalopathy. Improved QOL and a very low incidence of adverse events were observed.

Early Implantation as a Main Predictor of Response to Vagus Nerve Stimulation in Childhood-Onset Refractory Epilepsy.

OBJECTIVE: We describe a multicenter experience with vagus nerve stimulator implantation in pediatric patients with drug-resistant epilepsy. Our goal was to assess vagus nerve stimulation efficacy and identify potential predictors of favorable outcome. METHODS: This is a retrospective study. Inclusion criteria: ≤18 years at time of vagus nerve stimulator implantation, at least 1 year of follow-up. All patients were previously found to be unsuitable for an excisional procedure. Favorable clinical outcome and effective vagus nerve stimulation therapy were defined as seizure reduction >50%. Outcome data were reviewed at 1, 2, 3, and 5 years after vagus nerve stimulator implantation. Fisher exact test and multiple logistic regression analysis were employed. RESULTS: Eighty-nine patients met inclusion criteria. Responder rate (seizure frequency reduction >50%) at 1-year follow-up was 25.8% (4.5% seizure-free). At last follow-up, 31.5% had a favorable outcome and 5.2% were seizure free. The only factor significantly predicting favorable outcome was time to vagus nerve stimulator implantation, with the best outcome achieved when vagus nerve stimulator implantation was performed within 3 years of seizure onset. Implantation between 3 and 5 years after epilepsy onset correlated with better long-term seizure freedom (13.3% at T5). Overall, 65.2% of patients evidenced improved quality of life at last follow-up. However, 12.4% had adverse events, but most were mild and disappeared after 3-4 months. CONCLUSIONS: Early vagus nerve stimulator implantation within 5 years of seizure onset was the only predictor of favorable clinical outcome in pediatric patients. Improved quality of life and a low incidence of significant adverse events were observed.

Bathing epilepsy: report of two Caucasian cases.

Bathing epilepsy, also known as water-immersion epilepsy, refers to a rare form of benign reflex epilepsy in which seizures are precipitated by the normal process of domestic bathing. This condition has been confused with true hot water epilepsy, even though bathing in water at normal temperature is the trigger. Focal seizures predominate with a staring gaze, pallor and generalised features followed by prolonged postictal somnolence. A variable percentage of patients may also show unprovoked seizures. The prognosis is usually favourable, and modifying bathing habits may prevent further seizures. We report two Caucasian patients with bathing epilepsy. In one, seizures were provoked by water immersion. In the other, we noted an unusual triggering factor; pouring of lukewarm water over the genitalia.

A retrospective study on efficacy of the ERAS protocol in patients undergoing surgery for Crohn disease: A propensity score analysis.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) offers many benefits for patients with colorectal cancer. However, its application to patients with Crohn's disease (CD) is questioned. AIM: The aim of this propensity-matched study was to validate the results of ERAS protocol on CD patients. METHODS: Patients undergoing ileocolic resection for primary or relapsed CD from 2007 to 2018 were retrospectively analyzed and propensity-matched into two equal groups (ERAS vs standard of care). Demographic characteristics, length of stay, bowel function, oral intake, and perioperative morbidity were analyzed. RESULTS: Ninety four out of 299 patients were selected for analysis. No significant difference was observed for age, gender, American Society of Anesthesiologists score, body mass index, previous surgery and therapy, operative time and laparoscopy. The median length of stay in ERAS and non-ERAS groups was 6 and 8 days (p < 0.001). Median postoperative days of first bowel movement and solid oral intake were day 1 and day 2 p < 0,001, and day 2 and day 4.5 p < 0,001 in ERAS and non-ERAS group, respectively. No statistically differences in other postoperative outcomes were shown. CONCLUSIONS: ERAS implementation showed decreased length of stay, faster bowel function restoration and earlier solid oral intake in patients who underwent laparoscopic or open ileocolic resection for primary or relapsing CD.

Emergency surgery for bowel obstruction in extremely aged patients.

BACKGROUND: As a result of the increasing of life expectancy, the incidence of pathologies that can lead to operation for bowel obstruction is also increasing. Comorbidities and reduced physiological reserve can decrease elderly patients' ability to tolerate operations especially in an emergency context. We retrospectively evaluated the treatment and outcomes of a cohort of patients aged more than 85 years who underwent emergency surgery for intestinal occlusion. METHODS: Two hundred seventy-eight patients who were admitted to our Institution and operated for acute bowel obstruction have been included in our study. We divided the study population in 2 groups (group A: patients aged>85 years old; group B patients aged ≤85 years). We evaluated the differences between the two groups in terms of intestinal occlusion aetiology, surgical procedures, morbidity and mortality rates. RESULTS: Group A consisted of 57 patients, group B of 221; elderly patients trend in ASA score classification was significantly towards high risk for elderly group; statistical analysis did not show differences in terms of bowel obstruction etiology (except colon volvulus, more frequent in advanced age), type of procedure, duration of hospital stay, procedure-related complication rate. Perioperative mortality was significantly higher in elderly group, due to the mayor incidence of cardiovascular and respiratory fatal events directly related to pre-existing comorbidities. CONCLUSIONS: Despite the high surgical risk, early diagnosis and treatment of the obstructive disease can lead to achieve encouraging outcomes also in extremely advanced age; an aggressive evaluation of comorbidities and the cardiorespiratory risks reduction, when possible, could be useful in improve postoperative outcomes in terms of mortality.

Early surgical management of acute cholecystitis in ultra-octogenarian patients: our 5-year experience.

BACKGROUND: Acute calculous cholecystitis is a leading cause for hospital admission especially in developed countries. As older age population increases, medical research should consider the efficacy of all therapeutic options, including early surgical procedure in an emergency context, for the treatment of acute cholecystitis in elderly high-risk patients. METHODS: From 01/01/2012 to 31/12/2016, 245 patients were admitted to our Institution with diagnosis of acute cholecystitis and managed with cholecystectomy within the same hospitalization. The study population was divided into 2 subgroups: group A (patients aged more than 80 years) and group B (patients within the limit of 80 years of age); the objective of the study was to evaluate and compare the surgical outcomes of the 2 groups in terms of conversion rate, mortality rate, overall morbidity and procedure-related complication rates. RESULTS: Statistical analysis did not show significant differences between ultra octogenarian and younger patients in terms of conversion to open procedure, iatrogenic bile duct lesions, postoperative peritoneal bleeding, bile leakage and peritoneal collection; no differences in terms of hospital stay have been demonstrated. Mortality and overall morbidity rates, even if similar to what observed in Literature and within acceptable values, were significantly higher in elderly patients, due to the presence of severe comorbidities leading to potentially fatal postoperative events. CONCLUSIONS: Minimally invasive approach in an emergency setting for acute cholecystitis seems to be a feasible and adequate therapeutic approach for extremely aged high-risk patients.

Learning curve for endorectal ultrasound in young and elderly: lights and shades.

Aim of the study is to highlight difficulties faced by an inexperienced surgeon in approaching endorectal-ultrasound, trying to define when learning curve can be considered complete. A prospective analysis was conducted on endorectal-ultrasound performed for subperitoneal rectal adenocarcinoma staging in the period from January 2008 to July 2013, reported by a single surgeon of Department of Oncology, Section of General Surgery, "San Luigi Gonzaga" Teaching Hospital, Orbassano (Turin, Italy); the surgeon had no previous experience in endorectal-ultrasound. Fourty-six endorectal-ultrasounds were divided into two groups: early group (composed by 23 endorectal-ultrasounds, made from January 2008 to May 2009) and late group (composed by 23 endorectal-ultrasound, carried out from June 2009 to July 2013). In our experience, the importance of a learning curve is evident for T staging, but no statystical significance is reached for results deal with N stage. We can conclude that ultrasound evaluation of anorectal and perirectal tissues is technically challenging and requires a long learning curve. Our learning curve can not be closed down, at least for N parameter.

The learning curve of laparoscopic holecystectomy in general surgery resident training: old age of the patient may be a risk factor?

A well-designed learning curve is essential for the acquisition of laparoscopic skills: but, are there risk factors that can derail the surgical method? From a review of the current literature on the learning curve in laparoscopic surgery, we identified learning curve components in video laparoscopic cholecystectomy; we suggest a learning curve model that can be applied to assess the progress of general surgical residents as they learn and master the stages of video laparoscopic cholecystectomy regardless of type of patient. Electronic databases were interrogated to better define the terms "surgeon", "specialized surgeon", and "specialist surgeon"; we surveyed the literature on surgical residency programs outside Italy to identify learning curve components, influential factors, the importance of tutoring, and the role of reference centers in residency education in surgery. From the definition of acceptable error, self-efficacy, and error classification, we devised a learning curve model that may be applied to training surgical residents in video laparoscopic cholecystectomy. Based on the criteria culled from the literature, the three surgeon categories (general, specialized, and specialist) are distinguished by years of experience, case volume, and error rate; the patients were distinguished for years and characteristics. The training model was constructed as a series of key learning steps in video laparoscopic cholecystectomy. Potential errors were identified and the difficulty of each step was graded using operation-specific characteristics. On completion of each procedure, error checklist scores on procedure-specific performance are tallied to track the learning curve and obtain performance indices of measurement that chart the trainee's progress. CONCLUSIONS: The concept of the learning curve in general surgery is disputed. The use of learning steps may enable the resident surgical trainee to acquire video laparoscopic cholecystectomy skills proportional to the instructor's ability, the trainee's own skills, and the safety of the surgical environment. There were no patient characteristics that can derail the methods. With this training scheme, resident trainees may be provided the opportunity to develop their intrinsic capabilities without the loss of basic technical skills.

An unusual evolution of a case of Klippel-Trenaunay syndrome.

Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder. KTS can be diagnosed on the basis of any 2 of 3 features: cutaneous capillary malformations, soft tissue or bony hypertrophy and varicose veins. We present an unusual case of KTS complicated by an infection of venous ulcers of the lower limb by larvae. The treatment of infection was a complete debridement; however baseline treatment of KTS is still in evaluation.

Abnormal right hepatic artery injury resulting in right hepatic atrophy: diagnosed by laparoscopic cholecystectomy.

An intact hepatic artery is the gateway to successful hepato-biliary surgery. Introduction of laproscopic cholecystectomy (LC) has stimulated a renewed interest in the anatomy of hepatic artery. In this case report we have highlighted importance of variations of right hepatic artery in terms of origin and course We present a rare asymptomatic case of liver atrophy due to an intraoperative lesion of right hepatic artery. We also performed a literature review about surgical vascular lesions and tried to confirm the right concept behind "non trivial procedure" of the LC.

Meso-pancreatectomy for pancreatic neuroendocrine tumor.

We report a case of a meso-pancreatectomy performed on a pancreatic glucagonoma in a 58 years-old woman. MP is a conservative surgical treatment consisting in a resection of the body of the pancreas with the aim of reducing postoperative hormone insufficiency. This approach is curative in benign or low-malignant neoplasm of the central part of the pancreas.

Iron and Acinetobacter baumannii Biofilm Formation.

Acinetobacter baumannii is an emerging nosocomial pathogen, responsible for infection outbreaks worldwide. The pathogenicity of this bacterium is mainly due to its multidrug-resistance and ability to form biofilm on abiotic surfaces, which facilitate long-term persistence in the hospital setting. Given the crucial role of iron in A. baumannii nutrition and pathogenicity, iron metabolism has been considered as a possible target for chelation-based antibacterial chemotherapy. In this study, we investigated the effect of iron restriction on A. baumannii growth and biofilm formation using different iron chelators and culture conditions. We report substantial inter-strain variability and growth medium-dependence for biofilm formation by A. baumannii isolates from veterinary and clinical sources. Neither planktonic nor biofilm growth of A. baumannii was affected by exogenous chelators. Biofilm formation was either stimulated by iron or not responsive to iron in the majority of isolates tested, indicating that iron starvation is not sensed as an overall biofilm-inducing stimulus by A. baumannii. The impressive iron withholding capacity of this bacterium should be taken into account for future development of chelation-based antimicrobial and anti-biofilm therapies.

Difficult abdominal access in laparoscopic cholecystectomy in elderly patients: our experience and literature review.

Laparoscopic cholecystectomy (LC) is currently the gold standard treatment for symptomatic cholelithiasis. LC is actually condidered a medium complexity surgical operation. LC could be technically hard, especially if patient underwent previous surgical operation. These difficulties increase in outcome of previous operation in right upper quadrant (RUQ): in this case laparoscopic access is defined as an "hard access". We present two cases in which an unconventional access was performed: laparoscopic cholecistectomy is a safe and feasible procedure, although a careful assessment preoperative is indispensable. In particular, caution is required in both the triangulation of the trocar, which in pneumoperitoneum induction.

Percutaneous drainage and sclerosis of mesenteric cysts: literature overview and report of an innovative approach.

We present the case of a 29-years-old male patient, affected by a voluminous post-traumatic mesenteric cyst, a rare abdominal disease; our patient represents a rarely affected age group. Treatment was based on interventional radiology with an US-guided drainage and sclerosis by ethyl alcohol of the lesion. The intervention performed on this patient represents the application of a standardized radiological technique to a new contest, mesenteric cysts, whose gold-standard treatment is represented in literature by surgery. In our case we obtained an optimal result, with complete regression of the treated cyst: it proved to be an effective, feasible, safe and minimally invasive procedure.

Perioperative and postoperative outcomes of perforated diverticulitis Hinchey II and III: open Hartmann's procedure vs. laparoscopic lavage and drainage in the elderly.

Hartmann's procedure (HP) is the most performed technique for acute diverticulitis. Laparoscopic lavage and drainage (LLD) is an option evaluated as definitive treatment for diverticulitis Hinchey grade II-III. Aim of the study is to analyze and compare LLD vs HP outcomes. From January 1st 2009 and December 31st 2012 we prospectively enrolled 30 patients with diagnosis of acute diverticulitis Hinchey grade II-III. Fourteen patients underwent to LLD (LLD group, LLDG) and 16 patients to HP (Hartmann group, HG). We evaluated: demographic variables, comorbidities, admission clinical status, radiological imaging, intraoperative outcomes (operative time), postoperative outcomes (admission to ICU, timing of drainage removal, restore of bowel functions, timing of oral solid intake), mortality rate (perioperative and after 12 months) and morbidity rate (surgical, infectious, cardiovascular, renal and systemic complications). Exclusion criteria were: other diseases, colon cancer's suspect or diagnosis, conversion to HP. Patients' mean age was 64.8 years in HG and 62.6 in LLDG. M:F ratio was 6:10 in HG, 8:6 in LLDG. Data showed improved outcomes in LLDG for: total operative time (p < 0.0001), admission to ICU (p 0.0447), restoration of bowel functions (p 0.0035 for gases, p 0.0152 for feces), mobilization (p 0.0087) and length of hospital stay (p 0.0132). According to literature, LLD is related to operative risk, morbidity and mortality rate and length of stay lower than HP. LLD also gives the possibility to avoid stoma. Despite limits of our study, we consider LLD as a "safe and effective" treatment for Hinchey grade II-III acute diverticulitis.

Long-term follow-up in children with benign convulsions associated with gastroenteritis.

BACKGROUND: The outcome of benign convulsions associated with gastroenteritis (CwG) has generally been reported as being excellent. However, these data need to be confirmed in studies with longer follow-up evaluations. AIM: To assess the long-term neurological outcome of a large sample of children presenting with CwG. METHODS: We reviewed clinical features of 81 subjects presenting with CwG (1994-2010) from three different Italian centers with a follow-up period of at least 3 years. RESULTS: Follow-up period ranged from 39 months to 15 years (mean 9.8 years). Neurological examination and cognitive level at the last evaluation were normal in all the patients. A mild attention deficit was detected in three cases (3.7%). Fourteen children (17.3%) received chronic anti-epileptic therapy. Interictal EEG abnormalities detected at onset in 20 patients (24.7%) reverted to normal. Transient EEG epileptiform abnormalities were detected in other three cases (3.7%), and a transient photosensitivity in one (1.2%). No recurrence of CwG was observed. Three patients (3.7%) presented with a febrile seizure and two (2.5%) with an unprovoked seizure, but none developed epilepsy. CONCLUSIONS: The long-term evaluation of children with CwG confirms the excellent prognosis of this condition, with normal psychomotor development and low risk of relapse and of subsequent epilepsy.