Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study.

BACKGROUND: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. METHODS: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. RESULTS: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P < 0·001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. CONCLUSION: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2.

ANTECEDENTES: Las estrategias quirúrgicas están siendo adaptadas en presencia de la pandemia de la COVID-19. Las recomendaciones del tratamiento de la apendicitis aguda se han basado en la opinión de expertos, pero hay muy poca evidencia disponible. Este estudio abordó este aspecto a través de una visión de los enfoques mundiales de la cirugía de la apendicitis. MÉTODOS: La Asociación de Cirujanos Italianos en Europa (ACIE) diseñó una encuesta electrónica en línea para evaluar la actitud actual de los cirujanos a nivel mundial con respecto al manejo de pacientes con apendicitis aguda durante la pandemia. Las preguntas se dividieron en información basal, organización del hospital y cribaje, equipo de protección personal, manejo y abordaje quirúrgico, así como las características de presentación del paciente antes y durante de la pandemia. Se utilizó una prueba de ji al cuadrado para las comparaciones. RESULTADOS: De 744 respuestas, se habían completado 709 (66 países) cuestionarios, los datos de los cuales se incluyeron en el estudio. La mayoría de los hospitales estaban tratando a pacientes con y sin COVID. Hubo variabilidad en las indicaciones de cribaje de la COVID-19 y en la modalidad utilizada, siendo la tomografía computarizada (CT) torácica y el análisis molecular (PCR) (18,1%) las pruebas utilizadas con más frecuencia. El tratamiento conservador de la apendicitis complicada y no complicada se utilizó en un 6,6% y un 2,4% antes de la pandemia frente a un 23,7% y un 5,3% durante la pandemia (P < 0.0001). Un tercio de los encuestados cambió la cirugía laparoscópica a cirugía abierta debido a las recomendaciones de los grupos de expertos (pero carente de evidencia científica) durante la fase inicial de la pandemia. No hubo acuerdo en cómo filtrar el humo generado por la laparoscopia. Hubo una reducción general del número de pacientes ingresados con apendicitis y un tercio consideró que los pacientes atendidos presentaban una apendicitis más grave que las comúnmente observadas. CONCLUSIÓN: La pandemia ha demostrado que ha sido posible el tratamiento conservador de la apendicitis leve. El hecho de que algunos cirujanos cambiaran a una apendicectomía abierta podría ser el reflejo de las pautas deficientes que se propusieron en la fase inicial del SARS-CoV2.

Totally minimally invasive two-stage esophagectomy with intrathoracic hand-sewn anastomosis: short-term clinical and oncological outcomes.

Several esophageal resection techniques have been reported in literature. The objective of this study is to assess postoperative and oncological outcomes of two-stage minimally invasive esophagectomy (MIE) in a prone position using thoracoscopic hand-sewn anastomosis. Consecutive patients who underwent two-stage MIE in 2016 performed by the senior author were included. This was compared with the preceding cohort of consecutive patients who underwent two-stage hybrid esophagectomy (HE). The primary outcome was 30-day morbidity and mortality. The secondary outcomes were operation duration, length of stay (LOS), total nodes examined (TNE), number of positive nodes (NPN), and resection margin. Overall, 15 patients underwent MIE and 11 patients underwent HE. Respiratory complications occurred in three (20.0%) patients in the MIE group and in five (45.5%) patients in the HE group (P = 0.218). Cardiac complications occurred in two (18.2%) patients, and two other patients (18.2%) experienced anastomotic leak in the HE group. Mean operative duration was 349 ± 41.6 min in MIE and 309 ± 47.8 min in HE (P = 0.040). Median LOS was 10 days (range: 7-70) in MIE and 13 days (range: 10-116) in HE (P = 0.045). Median TNE was 23 (range: 12-36) in MIE and 20 (range: 14-47) in HE (P = 0.775). Longitudinal margin was involved in one patient (9.1%) in HE and no longitudinal margin was involved in the MIE group. Circumferential resection margin was involved in seven patients (46.7%) in MIE and in four patients (36.4%) in HE (P = 0.391). Two-stage MIE using hand-sewn technique is safe and feasible without compromising surgical and oncological outcomes. A multicenter large trial is recommended to confirm these results.

Multicenter clinical trial on the performance and tolerability of the Hyaluronic acid-collagenase ointment for the treatment of chronic venous ulcers: a preliminary pilot study.

BACKGROUND: Bed debridement is important to treat chronic wounds. Effective agents should remove the necrosis but protect the granulation tissue. We evaluated the performance and tolerability of a new composite ointment containing collagenase and hyaluronic acid for chronic venous ulcers. PATIENTS AND METHODS: Subjects with class 6 venous ulcers (CEAP classification) of at least 6 months duration were prospectively recruited. The ointment was administered daily and follow-up visits were conducted on the fifth, 10th, 15th and 20th days. On each visit the necrotic area was measured with a grid. The moisture balance, odour, viability of non-necrotic areas and the presence of erythema were also assessed. Primary outcome was the percentage of subjects with complete debridement, secondary outcomes the time to complete healing, reduction of the lesion area, absence of necrotic tissue, presence of odor, erythema, hydration, any adverse events. RESULTS: One hundred subjects were enrolled in four centres. All patients achieved complete debridement of the necrotic area and a significant reduction of the total ulcer area by day 20, while other parameters improved significantly over time. Only two patients experienced a transient leg oedema. CONCLUSIONS: The combination of collagenase and hyaluronic acid is safe and effective for chronic venous ulcers.

The role of radiofrequency surgery in the treatment of hemorrhoidal disease.

BACKGROUND: In this article we reported results obtained in our previous studies concerning application of radiofrequency (RF) in proctology and in particular for hemorrhoids treatment. METHODS: We compared radiofrequency submucosal hemorrhoidectomy (RSH) and conventional Parks' hemorrhoidectomy (CPH) (group 1), radiofrequency open hemorrhoidectomy (ROH) and Milligan-Morgan hemorrhoidectomy (MMH) (group 2), radiofrequency closed hemorrhoidectomy (RCH) and Ferguson hemorrhoidectomy (FH) (group 3), combined hemorrhoidal radiocoagulation (CHR) and rubber band ligation (RBL) (group 4). In this work primary endpoints were determined as evaluation of the grade of pain felt immediately after the procedure and at the first evacuation, bleeding, operation time, readmission to work, incidence of failures and patient's satisfaction. RESULTS: Group 1 - In comparison to Parks' technique, use of radiofrequency scalpel reduced mean operation time (61.2 min, range 50-75, vs. 37.4 min, range 30-51; p < 0.05), first postoperative day pain score (5.9, range 3-10, vs. 4.0, range 1-10; p < 0.05), pain score at first evacuation (5.7, range 2-10, vs 4.2, range 1-8; p < 0.05) and pain score on postoperative days (3.6, range 1-9, vs. 2.8, range 1-8; p < 0.05). Group 2 - Results show a substantial similarity between these techniques, however the procedure lasted 7 minutes less with RF scalpel (18.6 min, range 16-21, vs. 25.55 min, range 20-30; p < 0.05). Group 3 - Patients treated with RF showed significant reduction in surgical time (23 min, range 21-31, vs. 33 min, range 24-35; p < 0.01), in pain at 1st post-operative day (VAS score 3.4 +/- 1.3 vs. 4.8 +/- 1.0; p < 0.05) and at the first evacuation (3.4 +/- 1.0 vs. 5.0 +/- 0.8; p < 0.05). Group 4 - The study confirmed validity of both the used techniques, however CHR seems to allow a reduction in incidence of failures. CONCLUSIONS: Results obtained from radiofrequency surgery compared with those achieved with classic surgery for hemorrhoidal disease show in the majority of cases that radiosurgery facilitates, accelerates and improves surgical procedures.

Laparoscopic vs. open appendicectomies: results obtained by junior surgeons at a British University Hospital.

BACKGROUND: The laparoscopic approach for appendicectomies remains a frequent topic of debate. In this study we report the experience with laparoscopic (LA) and open appendicectomies (OA) achieved in a British University Hospital over one year where most of these operations have been conducted by junior trainees. METHODS: Retrospective review of LA and OA performed at the Whipps Cross University Hospital of London (U.K.). Outcomes measured were the operating time, length of hospital stay and post-operative complications. RESULTS: Between January and December 2008 205 appendicectomies have been performed on adult patients. Eighty-eight per cent of the procedures were conducted by junior surgeons. The operating time was significantly shorter for the OA vs. LA patients (55 +/- 26.8 vs. 83 +/- 26.9 min, p < 0.01). The hospital stay confirmed a significant advantage for LA (2.2 vs. 3.7 days, p = 0.02). No significant differences were present among techniques for the overall morbidity, post-operative intra-abdominal abscesses and rate of readmissions. CONCLUSIONS: Under adequate supervision LA can be safely performed by junior surgeons and reduces the hospital stay.

A retrospective study on mesh repair alone vs. mesh repair plus pedicle flap for large incisional hernias.

OBJECTIVE: Our experience with the treatment of large incisional hernias (IH) was reviewed comparing mesh repair alone vs. mesh repair plus pedicle flaps. MATERIALS AND METHODS: A retrospective study was performed on patients treated between 2001 and 2005 that underwent component separation technique (CST) repair with polypropylene mesh alone or with polypropylene mesh and local "pedicle" dermal flaps. The primary outcome evaluated was the recurrence rate, secondary outcomes the complication rate, hospital stay and reoperation rate. RESULTS: Forty-eight patients were reviewed. Six patients (13%) developed an IH recurrence, two of them (4%) required secondary repair. CST combined with prosthetic mesh repair and pedicle flap was performed in 19 patients (39.6%) while CST combined with mesh repair alone in 29 patients (60.4%). The duration of surgery, hospitalization, postoperative complications as well as long-term results were similar. CONCLUSIONS: Dermal pedicled flaps obtained through deepithelization of redundant skin following corrections of large incisional hernias are a safe, relatively easy and effective technique that allows reliable soft tissue coverage of the abdominal submuscular mesh.

A case of psoriasis with secondary amyloidosis, associated symbrachydactyly of the hand and a transverse deficiency of the foot.

Secondary amyloidosis is associated with a variety of chronic inflammatory diseases such as rheumatoid arthritis, ankylosing spondylitis, familial Mediterranean fever, osteomyelitis, inflammatory bowel diseases and infective or neoplastic conditions. Few cases of secondary amyloidosis complicating psoriasis have been reported. We describe a 58-year-old patient with secondary amyloidosis, psoriasis, an associated symbrachydactyly of the hand and a transverse deficiency of the foot. To the best of our knowledge, no case of this association has been previously reported.

Prospective evaluation of stapled haemorrhoidopexy versus transanal haemorrhoidal dearterialisation for stage II and III haemorrhoids: three-year outcomes.

INTRODUCTION: The aim of the study was to compare short- and medium-term outcomes of transanal haemorrhoidal dearterialisation (THD) versus stapled haemorrhoidopexy (SH) for the treatment of second- and third-degree haemorrhoids. METHODS: Patients with second- or third-degree haemorrhoids who failed conservative treatment were randomly allocated to THD or SH. Preoperative and postoperative symptoms, postoperative pain, time until return to normal activities, complications, patient satisfaction and recurrence rates were all assessed prospectively. Patients were followed up at 2, 8 months and when the study was completed. RESULTS: Twenty-eight patients (43% third degree) underwent THD and 24 (38% third degree) underwent SH. There were no significant differences in terms of postoperative pain, expected pain and analgesia requirements, but more THD patients returned to work within 4 days (P < 0.05). One THD patient developed a sub-mucosal haematoma after surgery, one SH patient occlusion of the rectal lumen and two rectal bleeding. At 8-month follow-up, two SH patients complained of faecal urgency. At 38-month follow-up (range 33-48 months), all short-term complications resolved. Patient satisfaction ("excellent/good outcome", THD 89 vs. SH 87%) and recurrence rate (THD 14 vs. SH 13%) were similar in the two groups. CONCLUSIONS: Short-term results although similar seem to suggest SH may result in increased morbidity while return to work is quicker after THD. Medium-term results demonstrate that THD and SH have similar effectiveness.

Ab initio calcineurin inhibitor-based monotherapy immunosuppression after liver transplantation reduces the risk for Pneumocystis jirovecii pneumonia.

At the Tor Vergata University of Rome, ab initio calcineurin inhibitor-based monotherapy immunosuppression (IS) is the standard of treatment after liver transplantation (LT). As the net state of IS determines the onset of Pneumocystis jirovecii pneumonia (PCP), we hypothesized that, in the presence of weak impairment of the immune function, as determined by the above-mentioned IS, the host is not overexposed to the risk for PCP and consequently the specific anti-PCP prophylaxis is unnecessary. In a single-cohort descriptive study, we retrospectively investigated the incidence of PCP in 203 LT patients who did not receive anti-PCP prophylaxis because they were under monotherapy IS. The primary endpoint of the study was the incidence of PCP during the first 12 months following LT; secondary endpoints were the incidence of acute rejection requiring additional IS and of CMV infection. No cases of PCP were recorded. The incidence of CMV and acute rejection was 3.9% and 0.9%, respectively. Our data suggest that monotherapy IS after LT may nullify the risk for PCP even in the absence of any specific prophylaxis.

Cryotherapy of the liver: a histological review.

INTRODUCTION: Cryotherapy has been largely used in the past for palliation of unresectable liver tumors, but high local recurrence rates and peculiar systemic complications have determined its progressive abandonment. This review analyzes the histological changes produced to provide the basis for the local recurrences. MATERIALS AND METHODS: A detailed literature search was performed on studies focusing on liver cryotherapy. Included were only those that described the histological characteristics in detail. RESULTS: A total of 22 studies were found, one clinical and the others in-vivo animal studies. Similar to other ablative techniques, cryotherapy produces a lesion which is composed by a central zone of coagulative necrosis surrounded with a transitional inflammatory zone. The lesion's dimensions and morphology are influenced by numerous factors including the probe temperature, diameter, the duration of freezing time, fast cooling rate, slow thawing rate, the number of freezing cycles and the inflow occlusion (Pringle maneuver). The temporal evolution is consistent across studies and leads to a progressive inflammatory invasion of the necrosis with definitive fibrotic substitution. CONCLUSIONS: Lesions obtained after cryotherapy seem similar and behave as those obtained after other techniques of liver ablation. However, controversial areas still exist and include the optimum number of freeze thaw cycles, the place of inflow occlusion, the potential corrupting effects of intra-lesional or proximal blood vessels on ablation morphology. The influence of these factors on the local recurrences are still not fully understood.

A rare case of cystic variety of angiomatoid fibrous histiocytoma.

A rare case of cystic angiomatoid fibrous histiocytoma of the thigh in a 13-years-old girl is reported. Final diagnosis was made only after surgical excision. A review of the literature with a discussion of the particularity of this case are also examined in order to achieve the best surgical strategy and the lower risk of recurrence.

Prediction of mortality in acute pancreatitis: a systematic review of the published evidence.

OBJECTIVE: In this review, we focus on studies that examined such prognostic indices in relation to predicting a fatal outcome from pancreatitis. SUMMARY BACKGROUND DATA: Acute pancreatitis (AP) is a common emergency, and early identification of high-risk patients can be difficult. For this reason, a plethora of different prognostic variables and scoring systems have been assessed to see if they can reliably predict the severity of pancreatitis and/or subsequent mortality. METHODS: All studies that focused on AP, including retrospective series and prospective trials, were retrieved and analysed for factors that could influence mortality. Articles that analysed factors influencing the severity of the disease or the manifestation of disease-related complications were excluded. RESULTS: 58 articles meeting the inclusion criteria were identified. Among the various factors investigated, APACHE II seemed to have the highest positive predictive value (69%). However, most prognostic variables and scores showed high negative predictive values but suboptimal values for positive predictive power. CONCLUSIONS: Despite the proliferation of scoring systems for grading AP, none are ideal for the prediction of mortality. With the exception of the APACHE II, the other scores and indexes do not have a high degree of sensitivity, specificity and predictive values.

Fatal hemorrhage in two renal graft recipients with multi-drug resistant Pseudomonas aeruginosa infection.

Pseudomonas aeruginosa (PA) infections occurring after renal transplantation (RT) represent a potentially life-threatening complication. We present 2 cases of early death following RT in which PA was transmitted, possibly from the donor to the recipients, despite preoperative cultures that were negative. The donor had developed PA-related bilateral pneumonia while in the intensive care unit. However, after appropriate antibiotic therapy, no signs of infection were present at the time of organ retrieval and cultures were negative. Both recipients received a renal graft from the same donor and developed multi-drug resistant (MDR)-PA infections with bacterial phenotypes and resistances similar to the donor. The first recipient died 9 days after RT from rupture of a false aneurysm of the external iliac artery, caused by a fully thickened PA-related arteritis. The second recipient died postoperatively on day 10 after rupture of an aneurysm in the right vertebral artery. Our experience shows that MDR-PA infection early after RT may be a catastrophic event. Specific anti-PA antibiotic therapy in RT patients during the perioperative period is recommended in the case of PA infection in the donor, even after apparent successful therapy with negative cultures.

Wound infections in body contouring mastopexy with breast reduction after laparoscopic adjustable gastric bandings: the role of smoking.

BACKGROUND: We retrospectively reviewed charts of 42 postbariatric patients who underwent mastopexy and breast reduction for body contouring to determine whether a significant relationship existed between cigarette smoking and postoperative wound infections and to determine the relative risk given by cigarettes and a cut-off value to predict infections. METHODS: We excluded patients with ongoing clinical infections, recent bariatric surgery (within 1 year), recent antibiotic courses, or systemic diseases such as arteriosclerosis and diabetes mellitus. RESULTS: All patients underwent bariatric surgery with the laparoscopic adjustable gastric bending technique and mastopexy with breast reduction for body contouring. Postoperative infections were present in 35.7% (n = 15) of patients, and 60% of these (n = 9) were superficial. Furthermore, 66.7% of them occurred in smoker patients, and 41.7% of smokers vs. 27.8% of nonsmokers developed infections. Significant differences between infected vs. infection-free patients were present for the number of pack years (p < 0.001) and the overall estimated cigarettes smoked (p < 0.001). A cut-off value of approximately 6.85 pack years (50,000 overall estimated cigarettes) distinguished between infections vs. infections-free patients, with 25% of false positives and 8% of false negatives. Relative risk conferred by smoking was 3.8. CONCLUSIONS: The incidence of infections in our series of postbariatric patients undergoing mastopexy and breast reduction is 35.7%. A cut-off of 6.85 pack years (50,000 estimated overall cigarettes) was determined and, according to this value, the relative risk conferred by smoking was 3.8.

Vaginal reconstructive surgery for severe pelvic organ prolapses: a 'uterine-sparing' technique using polypropylene prostheses.

OBJECTIVE: The Ulmsten's "Integral Theory" for pelvic floor dysfunctions is based on the need to reinforce fascias and ligaments with prostheses to obtain a reconstitution of the pelvic floor's anatomy. In September 2004 we developed a "uterine-sparing" surgical technique to correct such pathologies and in this paper we present results obtained. Primary outcome was to evaluate the technique's efficacy, secondary outcomes the resolution of stress urinary incontinence, postoperative pain (VAS scale), safety and complications. STUDY DESIGN: This prospective study included patients affected by stage 3 and 4 uterine-vaginal prolapse who wished to conserve their uterus. Those with (1) minor degrees of severity, (2) unfit for surgery, (3) with a clear indication to hysterectomy (i.e. endometrial cancer), (4) with an elevated operative risk (American Society of Anaesthesiologists-ASA score III and IV), (5) previous vaginal surgeries and (6) with moderate/severe defecation problems were excluded. The technique consisted in a sacrospinous colposuspension with polypropylene mesh. The pelvic status was classified according to the international Pelvic Organ Prolapse staging system (POP-Q). Postoperative pain was scored with the VAS Scale. All patients were given the King's Health questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Wexner questionnaire. RESULTS: From September 2004 to November 2006 we treated 80 patients. Polypropylene prostheses (Gynemesh-Soft PS, 10cmx15cm - GyneMesh, Gynecare Ethicon - Somerville, NJ, USA) were used to reconstruct the pubo-cervix or the recto-vaginal fascia. We performed an anterior-central vaginal reconstruction in 35 (43.8%) patients, central-posterior in 25 (31%) and total reconstruction in 20 (25%). The median follow-up was 21 months (range 18-26). The severe pelvic prolapse, evaluated with the POP-Q System, was completely treated in all the patients and no recurrences were observed. The urodynamic examination showed a complete resolution of the stress urinary incontinence in 10 patients (83%). Sexual activities improved in all patients. We recorded three vaginal erosions and one patient complained of a postoperative dyspareunia. CONCLUSIONS: This pilot study suggests that our technique is safe and effective and can efficiently repair the pelvic organs prolapse, without undergoing hysterectomy and with a low rate of vaginal erosions.

Inverse relationship between the apoptotic rate and the time elapsed from thermal injuries in deep partial thickness burns.

BACKGROUND: The purpose of this article was to further describe apoptotic behaviour in deep partial thickness burns, correlating the apoptotic rate of these lesions with the time elapsed from injury. METHODS: We used TUNEL and Fas immunohistochemistry in serial biopsies of deep partial thickness burns harvested from 1 to 23 days following injury. The apoptotic rate was defined as the number of apoptotic cells out of the total number of nucleated cells. RESULTS: We recruited 25 subjects. Apoptosis was present in all biopsies and showed an inverse relationship with the time elapsed from thermal injury, higher during the first days and lower in the third week (r=-0.518; p=0.008). No significant correlations were demonstrated with age, total burn surface area, deep partial thickness burns area, Baux UBS index. CONCLUSIONS: Our study demonstrates that apoptosis persists in deep partial thickness burns throughout the first 3 weeks and shows an inverse relationship with the time elapsed from injury. It provides, in our opinion, the basis for future investigations regarding correlation with local vascularity and perfusion status and with clinical outcomes of deep partial thickness burns.

Wound infections in post-bariatric patients undergoing body contouring abdominoplasty: the role of smoking.

BACKGROUND: In this prospective study, we followed patients after laparoscopic adjustable gastric banding for morbid obesity who underwent abdominoplasty for body contouring. Our purposes were: 1) to determine if a significant relationship between cigarette smoking and postoperative wound infections existed, 2) the relative risk conferred by cigarettes and 3) a cut-off value for the increased risk. METHODS: Patients scheduled for body contouring abdominoplasty were considered eligible. We excluded those with ongoing clinical infections, recent antibiotic administration, those within 1 year from their bariatric surgery and those with systemic diseases. Smokers were asked to stop smoking at least 4 weeks before surgery. RESULTS: Since November 2004, we recruited 60 patients. Postoperative infections were present in 25% (n=15) of patients and 86.7% of these (n=13) were superficial. All except one occurred in smokers (P = 0.0001): 47% of smokers and 3% of nonsmokers developed infections. Significant differences between infections vs infection-free patients were present for the number of cigarettes smoked per day (P<0.001), years of smoking (P< 0.001), overall estimated cigarettes smoked and the number of pack years (P = 0.001). A cut-off value of approximately 62,000 overall estimated cigarettes (8.5 pack years) distinguished between infections vs infection-free patients (6.2% false positives and 7.1% false negatives). Relative risk conferred by smoking was 14 (95% confidence intervals 13.3-16.7). CONCLUSIONS: The incidence of infections in post-bariatric patients undergoing body contouring abdominoplasties is 25%. The relative risk conferred by smoking was 14 and the cut-off value was 62,000 overall cigarettes (8.5 pack years).

Devastating methicillin resistant Staphylococcus aureus wound infection following abdominoplasty in a prior bariatric surgery patient.

A 46-year-old female smoker presented 12 months after laparoscopic adjustable gastric banding, with massive weight loss and skin excess of the abdomen and flanks. She underwent abdominoplasty with muscle plication and flanks liposuction, but on the 14th postoperative day this was complicated by a methicillin-resistant Staph. aureus wound infection. Multiple surgical debridements and high doses of intravenous antibiotics were necessary for cure and to avoid further septic complications. Complete wound closure was achieved after 3 months of therapy. Concomitant risk factors for wound infection (obesity, smoking, flap construction) contributed to a rare but potentially fatal wound complication following abdominoplasty. We alert the surgeon to such postoperative infections and the necessity for a non-conservative approach.

Post-endoscopic polypectomy delayed bleeding concomitant with an abdominoperineal resection: a case report.

We describe the case of a delayed bleeding that occurred concomitantly with an abdominoperineal resection. The patient underwent endoscopy without apparent complications. During surgery, and in the immediate postoperative hours, 4 blood units were required to achieve stable conditions even if the surgical technique was correct, no major bleeding occurred and no blood was seen inside the lumen at bowel transection. On the 7th postoperative day (9th from polypectomy) the patient shocked for the first time. Two days later, massive clots appeared from the stoma and he shocked again. CT scan found the bleeding occurring from the polypectomy site and angiographic embolization finally ended the hemorrhage. The increased risk of delayed hemorrhages and their dramatic clinical manifestations render the post-polypectomy "window" period worth to be followed-up strictly. We believe that further invasive procedures, especially major surgery, should be postponed unless emergent and necessary to save the patient's life.

Fluoroquinolones-induced tendinitis and tendon rupture in kidney transplant recipients: 2 cases and a review of the literature.

Fluoroquinolones are an important class of synthetic antibiotics and their use recently expanded with a new activity against Gram positive and anaerobics. In the literature many side effects were documented and, among them, tendinitis and subsequent tendon rupture are important causes of morbidity. The incidence is 0.14% to 0.4% but, in the kidney recipient population, the phenomenon is even more common (incidence, 12.2%-15.6%). Advanced age seems to be the most significant risk factor. Long period of hemodialysis, diabetes mellitus, hyperparathyroidism, rheumatic diseases, gout, and corticosteroids are the other predisposing factors in kidney recipients, even if they are still under discussion. All of these risk factors can create a synergistic toxicity or at least an additive effect. A case of tendinitis and a case of bilateral Achilles tendon ruptures in 2 kidney recipients are described and a brief discussion of the literature is presented.