The impact of age on quality of life and frailty outcomes after parathyroidectomy in patients with primary hyperparathyroidism.

OBJECTIVE: Parathyroidectomy (PTx) improves quality of life (QoL) in patients with primary hyperparathyroidism (PHPT). Whether this effect is modified according to the patients' age is unknown. The aim of this study was to evaluate the impact of age on the effect of PTx on QoL and frailty in patients with PHPT, six months post-PTx. METHODS: This was a prospective cohort study, including patients with PHPT, admitted from January 2016 to December 2019, divided into two categories: younger (≤ 65 years old) and older (> 65 years old). QoL was assessed with the Pasieka questionnaire (PAS-Q) two days pre- and six months post-operatively. Frailty was also assessed at the same time intervals, with the Frailty Index (FI). RESULTS: One hundred and thirty-four patients (younger group: 96 patients, mean age 50.4 ± 9.8 years; older group: 38 patients, mean age 72.1 ± 4.9 years) were included. PTx resulted in a significant reduction in PAS-Q score in both groups. Notably, a greater reduction in "mood swings", "irritability", "itchy skin" and "feeling thirsty" PAS-Q domains was observed in the younger group. In contrast, a greater decrease in "bone pain", "tiredness", "weakness", "joint pain", "getting off chair" and "headaches" items was observed in the older group. Moreover, PTx led to a decrease in FI only in this group. CONCLUSIONS: PTx leads to an improvement in QoL both in older (> 65 years) and younger (≤ 65 years) patients with PHPT, attributed to a differential effect on PAS-Q items. Frailty improves only in the older group.

Multi-drug-resistant gram-negative bacterial infection in surgical patients hospitalized in the ICU: a cohort study.

We sought to identify risk factors for postoperative infections, caused by multi-drug-resistant gram-negative bacteria (MDR-GNB) in surgical patients. This was a retrospective cohort study among patients hospitalized in the intensive care unit (ICU) for more than 5 days, following general surgical operations. Comparison of patients who developed infection caused by MDR-GNB with the remainder of the cohort showed that every minute of operative time, use of special treatments during hospitalization (antineoplastic, immunosuppressive or immunomodulating therapies), every day of metronidazole, and every day of carbapenems use, increased patients' odds to acquire an infection caused by MDR-GNB by 0.7%, 8.9 times, 9%, and 9%, respectively [OR (95% CI): 1.007 (1.003-1.011), p = 0.001; 8.9 (1.8-17.3), p = 0.004; 1.09 (1.04-1.18), p = 0.039; 1.09 (1.01-1.18), p = 0.023, respectively]. The above were adjusted in the multivariable analysis for the confounder of time distribution of infections caused by MDR-GNB. Finally, the secondary comparison, with patients that did not develop any infection, showed that patients who had received antibiotics, within 3 months prior to admission, had 3.8 times higher odds to acquire an infection caused by MDR-GNB [OR (95% CI): 3.8 (1.07-13.2), p = 0.002]. This study depicts certain, potentially modifiable, risk factors for postoperative infections in patients hospitalized in the ICU for more than 5 days.

Surgical management of rectal prolapse.

PURPOSE: Rectal prolapse is uncommon; however, the true incidence is unknown because of underreporting, especially in the elderly population. Full-thickness rectal prolapse, mucosal prolapse and internal prolapse are three different clinical entities, which are often combined and constitute rectal prolapse. The aim of the study is to present our experience in the surgical management of rectal prolapse. METHODS: In a 6-year period (2004-2010), 27 patients were surgically treated for rectal prolapse. The majority of patients were women (25 women, two men) and their mean age was 72.36 years. The operations performed were two Delorme's procedures, five STARR (Stapled TransAnal Rectal Resection), 14 Wells procedures, two Wells combined with Thiersch, one Altemeier, one sigmoid resection combined with Wells and two Thiersch. RESULTS: An emergency sigmoidostomy was performed on a patient after Wells operation due to obstructive ileus. One death occurred on the 5th postoperative day due to pulmonary embolism. Two recurrences observed 8 months postoperatively, one in a patient after STARR operation and one in a patient after Thiersch technique. The great majority of patients are completely relieved of symptoms. CONCLUSIONS: The application of different modalities in the treatment of rectal prolapse is attributed to the fact that cause, degree of prolapse and symptoms, vary from one patient to another. Successful approach depends on many factors, including the status of a patient's anal sphincter muscle before surgery, whether the prolapse is internal or external and the overall condition of the patient.

A retrospective analysis of 2000 cases with colorectal carcinoma.

PURPOSE: Colorectal cancer (CRC) is a major cause of death in the western world and a leading cause of cancer-related death. It is one of the most common human malignancies with >300,000 cases both in the United States and in the European Union each year. The present study was conducted to assess differences in various variables of CRC, such as location of the tumor, differentiation, Dukes classification, 5-year survival and possible changes in these patterns during the examined period. METHODS: We collected data on 2000 patients with colorectal cancer, diagnosed and treated from 1960 to 2008 in 1st Propedeutic Surgical Clinic of Aristotle's University, Thessaloniki. RESULTS: Of 2000 cases reviewed, cancer was almost equal presented to both sexes, for all groups. Rectum was the most common tumor location in all analyzed groups (40.1%). The most common tumor differentiation was the moderate one (68.5%). Concerning tumor staging, Dukes' B tumors were most common (42.5%), and the cancer-related 5-year survival was increased by the time from 42 to 71%. CONCLUSION: In the past 20 years, considerable improvements have been made in colorectal cancer therapy, and patients had received more sophisticated and multidisciplinary treatments, resulting in a better 5-year survival rate.

Rectal endometriosis: a case report.

We present the case of a 45-year-old female patient who was admitted with a history of pelvic pain, constipation, and dysmenorrhea. CT scan and u/s images revealed cholelithiasis, benign nodular hyperplasia of segment IV of the liver and uterine fibromyoma. During laparotomy, firm adhesions between the posterior wall of the uterus and the rectum were found and the incisional biopsy reveals an undifferentiated adenocarcinoma. Then, total resection of the uterus was performed with en block resection of the adherent part of the rectum and part of the posterior wall of the vagina. The final histopathological report showed the presence of uterine fibromyoma, nodular hyperplasia of the liver and rectal endometriosis without any sign of malignancy. The patient after 5 years of follow up remains healthy. Rectal endometriosis represents an uncommon localization of pelvic endometriosis where the symptoms and clinical findings are non-specific making the definitive preoperative diagnosis difficult. Endometriosis should be included in the differential diagnosis of chronic pelvic pain in combination with defecation disorders in female patients of reproductive age.

Gossypiboma presenting as mesosigmoid abscess [corrected].

INTRODUCTION: The term "gossypiboma" is used to describe any mass of non-absorbable surgical material. It is estimated that this complication appears every 1.000-10.000 procedures. It may lead to peritonitis, acute abdominal pain, intraperitoneal abscess, bowel obstruction, or perforation. REPORT OF A CASE: We present the case of an 80-year-old female patient admitted for chronic abdominal pain and fever. A CT scan and MRI were performed with a probable diagnosis of carcinoma or pelvic abscess. A surgical history of hysterectomy and repair of abdominal wall hernia with a mesh were mentioned. RESULTS: Exploratory laparotomy revealed the presence of an irregular, soft mass with characteristics of an abscess located into the mesosigmoid. Hartman's sigmoidectomy was performed, and the patient's postoperative course was uneventful. The histopathological examination confirmed the diagnosis of gossypiboma. CONCLUSIONS: Retained foreign intraperitoneal materials often represent diagnostic dilemmas, since symptomatology is no specific and the time elapsed from surgery is long. The policy of prevention's importance is highly appreciated.

Surgical management of colorectal injuries: colostomy or primary repair?

PURPOSE: Several factors have been considered important for the decision between diversion and primary repair in the surgical management of colorectal injuries. The aim of this study is to clarify whether patients with colorectal injuries need diversion or not. METHODS: From 2008 to 2010, ten patients with colorectal injuries were surgically treated by primary repair or by a staged repair. RESULTS: The patients were five men and five women, with median age 40 years (20-55). Two men and two women had rectal injuries, while 6 patients had colon injuries. The mechanism of trauma in two patients was firearm injuries, in two patients was a stab injury, in four patients was a motor vehicle accident, in one woman was iatrogenic injury during vaginal delivery, and one case was the transanal foreign body insertion. Primary repair was possible in six patients, while diversion was necessary in four patients. CONCLUSIONS: Primary repair should be attempted in the initial surgical management of all penetrating colon and intraperitoneal rectal injuries. Diversion of colonic injuries should only be considered if the colon tissue itself is inappropriate for repair due to severe edema or ischemia. The role of diversion in the management of unrepaired extraperitoneal rectal injuries and in cases with anal sphincter injuries is mandatory.

Changes in treatment of rectal cancer: increased use of low anterior resection.

PURPOSE: The most common surgical procedures for patients with rectal cancer are low anterior resection (LAR) or abdominoperineal excision (APE). The aim of the present study is to evaluate and report the changes in the incidence of LAR and APE in the surgical treatment of rectal cancer over the last 15 years in a single surgical department. METHODS: The patient sample consisted of 251 consecutive patients (mean age 65.17; age range 22-87) that underwent surgical treatment for rectal cancer in a single center from 1996 to 2010. This time frame was divided into three 5-year periods (1996-2000, 2001-2005 and 2006-2010). Patients were classified into one of the aforementioned groups, depending on the date of their treatment. RESULTS: In the first period (1996-2000), 71 patients were treated for rectal cancer. Among them, 32.4% (n = 23) underwent an abdominoperineal excision (APE) while 56.3% (n = 40) were treated with LAR. In the second period (2001-2005), included 102 patients, from which 29.4% (n = 30) received an APE and 60.8% (n = 62) underwent a LAR for their disease. In the final period (2006-2010), from the 78 patients, only 12.8% (n = 10) of them underwent APE, while 74.3% (n = 58) were treated with LAR. There was a statistically significant (chi-square test, P = 0.005) difference between the 3 periods of time concerning the performance of LAR and APE. CONCLUSIONS: According to the results of the present study, the rates of APE seem to decrease during the last 15 years, while LAR is more widely used in the surgical treatment of rectal cancer.

Inflammation of solitary caecal diverticula:a rare aetiology of acute abdominal pain [corrected].

Caecal diverticula are rare, representing the 3.6% of colonic diverticula. They may have congenital origin and remain asymptomatic, presenting as an accidental finding. We present a case of a 42-year-old Caucasian woman, admitted with a 12-h history of sudden onset of sharp right iliac fossa pain, anorexia, and nausea. There was leukocytosis (23.49 × 10(3)/µl) and increased C-reactive protein (11.76 mg/dl). CT scan showed an inflamed appendix. At laparotomy, a diffuse caecal phlegmon with an inflammatory solitary caecal diverticula was found. A limited right hemicolectomy was performed. Histological examination confirmed the caecal diverticulitis without malignancy. Post-operative period was uneventful. Three months later, endoscopy showed no diverticula or other pathologies. Solitary caecal diverticulum is very rare, but surgeons must bear this in mind in case of pain in right iliac fossa.

Epidemiological aspects of 2009 H1N1 influenza: the accumulating experience from the Northern Hemisphere.

Preliminary data regarding the experience of countries of the Northern Hemisphere with pandemic 2009 A(H1N1) influenza have already appeared in the literature. We aimed to evaluate the available published literature describing the epidemiological features of pandemic influenza. We searched PubMed; 35 studies (14 referred to European countries, eight to the USA, five to Mexico, four to Canada, two to Japan, one to Colombia, and one reviewed relevant data reported worldwide) were included. Considerably high hospitalization, intensive care unit (ICU) admission, and fatality rates (up to 93.8, 36.4, and 38.5%, respectively) among the evaluated cases were reported across studies with available relevant data. Young and middle-aged adults constituted the majority of the evaluated pandemic cases, with different disease severity (as indicated by the level of care and outcome). Yet, substantial percentages of elderly individuals were reported among more severely afflicted cases. Otherwise healthy patients constituted substantial percentages among evaluated cases with different disease severity. Pregnant women, obese, and morbidly obese patients also constituted substantial percentages of the cases involved in the included studies. The evaluation of the currently available published evidence contributes to the clarification of the epidemiological features of pandemic 2009 A(H1N1) influenza, which is useful in terms of the individual and public health perspectives.

Inhaled anti-infective agents: emphasis on colistin.

The administration of antibiotics by the inhaled route is a widely recognized treatment in patients with cystic fibrosis (CF) and bronchiectasis. Tobramycin solution for inhalation (TOBI) has been available for many years and is licensed in the USA and Europe. While strong data support the use of aerosolized antibiotics for the treatment of respiratory infections in patients with CF or bronchiectasis, only a few clinical studies have examined the role of aerosolized antibiotics in the treatment of pneumonia, including ventilator-associated pneumonia (VAP) in these patients. During the last decade increasing interest has been directed towards alternative treatments to the systemic administration of antimicrobial agents for the treatment of patients with hospital-acquired pneumonia or VAP due to multidrug-resistant (MDR) Gram-negative bacteria. Recent publications demonstrate the clinical benefits from administering inhaled aminoglycosides or polymyxins in patients with hospital-acquired pneumonia or VAP. In addition to antibiotics, antifungals, and antivirals have been administered by inhalation to specific groups of critically ill patients. However, randomized controlled trials dealing with the administration of anti-infective agents via the respiratory tract are necessary in order to validate the efficacy, safety, advantages, and disadvantages of this therapeutic approach for the treatment of nosocomial pneumonia.

Comparison of the distribution of citations received by articles published in high, moderate, and low impact factor journals in clinical medicine.

BACKGROUND: Whether the journal impact factor (JIF) indicator reflects the number of citations to an average article of a journal in different subject categories is controversial. We sought to further investigate this issue in general and internal medicine journals. METHODS: We selected to evaluate three journals of the above subject category, in each of three different JIF levels (high: 15.5-28.6, moderate: 4.4-4.9 and low: 1.6). Using the Scopus database, we retrieved the original research articles (after detailed screening) and review articles (as classified by Scopus) that were published in the selected journals in 2005 along with the number of citations they received in 2006 and 2007. We pooled the citations for articles of the same type in journals with the same JIF level into distinct variables. RESULTS: There was no marked association between the distribution of citations per article published in general medical journals and their JIF. All distributions studied were skewed to the right (higher number of citations). Specifically, 16-22% of the original research articles accounted for 50% of the total citations to this type of article for all three categories of studied journals; 34-37% of original research articles accounted for 75% of citations. The respective values for review articles were 12-18% and 29-39%. CONCLUSION: The distribution of citations received by articles published in high, moderate and low impact factor journals in clinical medicine seems similar. The JIF is not an accurate indicator of the citations the average article receives; articles published in low impact factor journals can still be highly cited and vice versa.

Ileal pouch dysfunction.

The causes of pouch dysfunction are inflammatory, non-inflammatory and iatrogenic. The most common long-term complication is pouchitis. Diagnosis should be based on clinical symptoms, endoscopic appearance and histologic findings. Ciprofloxacin and metronidazole are the treatment of choice for pouchitis. Fistulae and perianal abscesses should be suspected to be an expression of misdiagnosed Crohn's disease. Strictures are confronted by endoscopic balloon dilatation. Patients who will be refractory to all forms of medical treatment should have surgical treatment such as faecal diversion or pouch revision.

Perianal fistulas.

The most common cause of anal fistula is anal gland sepsis, resulting in formation of anorectal abscess, particularly if the latter allowed bursting spontaneously or has been inadequately opened at operation. Surgical treatment of the fistula must intent to its healing or simply its drainage or its transformation to a simpler one. Superficial, low transsphincteric and intersphincteric fistulas are treated by the lay-open technique. The use of a loose seton allows time for any sepsis and induration to settle before a decision about further treatment is made. Also, the use of a tight seton in the management of complex fistula may avoid an early muscle division before any tissue scarring happened. The patient with a perianal fistula must have a steady trustful relationship with his surgeon and must be fully informed on the therapeutic plan and reassured for a favourable outcome.

Enhancement of colonic anastomotic strength in rats by short-chain fatty acids.

BACKGROUND: The present study is aiming at elucidating the effect of intraoperative lavage with short-chain fatty acids (SCFAs) on colonic anastomosis in rats. METHODS: Forty male Wistar rats were randomized into four groups (10 rats each). After resection of a segment of transverse colon, an end-to-end anastomosis was performed. In the 1st group, no intraoperative large bowel lavage was performed; in the 2nd, a lavage with normal saline solution; in the 3rd, the animals received a diet rich in SCFAs pre- and postoperatively, and a lavage with normal saline was performed; and in the 4th group, an intraoperative lavage with SCFAs was carried out. On the 4th postoperative day, the animals were sacrificed. Septic complications, adhesions and anastomoses were graded macroscopically and histologically, and bursting pressure of the anastomoses, CRP, IL-6 and TNF-a was measured. RESULTS: Fewer septic complications (abscesses and minimal ruptures) and adhesions were observed in the 4th group with the intraoperative lavage with SCFAs. The bursting pressure also, in the same group, was higher (73.3 mmHg), followed by the 1st group (67.1 mmHg). CONCLUSION: Intraoperative lavage with SCFAs increases the bursting pressure of colonic anastomoses, while lavage with saline solution decreases it, in comparison to the group without lavage.

The use of fibrin glue in the treatment of complex perianal fistulae: a case report.

We present a 71-year-old man with a horseshoe, complex perianal fistula. He was treated by a simple fistulotomy for the fistula at sixth hour, while fibrin sealant was applied for the complicated one. He is free of symptoms 24 months postoperatively.

Colonic cancer in a patient with intestinal malrotation: a case report.

We present a case of a 76-year-old patient with intestinal malrotation, with incomplete rotation of the small intestine and abnormal positioning of the duodenum and superior mesenteric vessels over the transverse colon. Furthermore, the patient suffered of a concomitant cancer of the ascending colon.

Desmoid tumor of mesentery in familial adenomatous polyposis: a case report.

Our case concerns a 52-year-old male with FAP, who was treated surgically by restorative colectomy and ileal pouch anal anastomosis. Three years later, he presented with acute epigastric pain and obstructive ileum. While a mass in the left lateral abdominal region was palpated. The patient underwent laparotomy, some adhesions were dissected and biopsies were taken from the mass. Pathological examination revealed a desmoid tumor of the mesentery.

Prospective clinical trial comparing sphincterotomy, nitroglycerin ointment and xylocaine/lactulose combination for the treatment of anal fissure.

BACKGROUND: The aim of this study is to compare the ability of three treatments in patients with anal fissure, sphincterotomy, nitroglycerin ointment and combination of gel xylocaine and lactulose. METHODS: Ninety adults divided in three groups of 30 patients each group, received one of the three treatments in a 3-year interval (2007-2009) and the follow-up was for 2 months. Group A received nitroglycerin ointment, Group B underwent sphincterotomy and Group C received gel xylocaine and lactulose. RESULTS: Concerning pain, after treatment 60% of patients in Group A did not complain of pain, 20% had transient pain, another 10% moderate pain and the remaining 10% had severe pain. In Group B, 95% of the patients had no pain and only 5% had mild, transient pain. In Group C 60% of the patients had moderate pain and the other 40% suffered from severe pain. Concerning fissure healing, in 60% of the patients of Group A, the fissure was healed. In Group B fissure healed in 93.3% and in Group C only in 16.6% of the patients. CONCLUSION: The "gold standard" for anal fissure treatment is the lateral internal sphincterotomy and that each one of the three methods has its advantages and disadvantages.

Gallstone obstructive ileus 3 years post-cholecystectomy to a patient with an old ileoileal anastomosis.

The present case is one of gallstone obstructive ileus due to gallstones 3 yr after laparoscopic cholecystectomy. It is interesting because of the sex of the patient, the fact that ileus occurred 3 yr after cholecystectomy and that the localization of the obstruction was an old side-to-side ileoileal anastomosis due to a diverticulectomy following intussusception of Meckels' diverticulum at the age of 3.