Management of blunt hepatic and splenic injuries (grade ≤ III) in patients receiving antithrombotic therapy.

BACKGROUND: Non-operative management (NOM) may be particularly challenging in patients receiving synchronous antithrombotic therapy (AT). The current study examined the feasibility of NOM in patients under AT who sustained blunt splenic or hepatic injuries. METHODS: We analyzed the results of a 5-year (2010-2014) pre-decided treatment protocol, including 15 patients under AT who were treated for splenic and/or hepatic injuries at our institution. The antithrombotic therapy consisted of acenocoumarol 4 mg, acetylsalicylic acid 100 mg and clopidogrel 75 mg. Vitamin K (Vit K), Fresh frozen plasma (FFP) and Prothrombin Complex Concentrate (PCC) were transfused to patients receiving anticoagulant therapy, while platelets (PLTs) were given to patients under antiplatelet therapy if their level was excessively low. The organ injury grading scale, injury severity score (ISS), the need for blood transfusion and intensive care unit (ICU)/ high dependency unit (HDU) admission, morbidity, mortality and duration of hospital stay were also recorded. RESULTS: Ten patients fulfilled the criteria for NOM and were treated accordingly. No conversion to operative management (OM) was required (success rate 100%). Five patients were managed surgically due to hemodynamic instability and/or signs of peritonitis. Reversal of AT was attempted in all cases. CONCLUSIONS: Hemodynamically stable patients under AT with blunt hepatic or splenic injuries (grade ≤ III) and no signs of peritonitis, may be good candidates for NOM, despite their bleeding tendency. The type of AT does not seem to influence the final outcome. Reversal of AT should be stratified individually. KEY WORDS: Antithrombotic therapy, Hemodynamic stability, Non-operative management.

Successful non-operative management of blunt abdominal trauma in highly selective cases: A safe and effective choice.

BACKGROUND: The non-operative management (NOM) of abdominal injuries has gained wide acceptance over the last few decades. The present study evaluated the efficacy of NOM in blunt abdominal trauma (BAT) at a regional Hellenic hospital. METHODS: We analyzed the results of a pre-decided treatment protocol, which was applied to all patients hospitalized for BAT, from 2008 to 2015. The protocol proposed NOM in hemodynamically stable patients with no signs of peritonitis. The demographic characteristics, type of injury, injured organ(s), type of management (operative vs. non-operative), Injury Severity Score (ISS), morbidity, mortality rates, and health costs were evaluated. RESULTS: One hundred and forty-six patients hospitalized for BAT at our department were included. Among them, 49 were operated and 97 were subjected to NOM. Although ISS was significantly higher in the surgical group, the severity of injuries in liver, spleen, and kidneys was not different between the two groups. Surprisingly, no case subjected to NOM required a conversion to operative management, which may probably be because of the strict inclusion criteria for NOM. CONCLUSION: Patients with hemodynamic stability and normal physical examination may be non-operatively treated, independent of the grade of injury, in highly selective cases. ISS score is an independent risk factor for surgical treatment.

Entero-vesical fistulas in CROHN'S disease: A case series report and review of the literature.

BACKGROUND: Entero-vesical fistula (EVF) is an abnormal link between the enteric lumen and the urinary bladder. Crohn's disease (CD) represents, nowadays, the most common cause in the formation of this fistula. MATERIALS AND METHODS: The aim of this study was to describe the diagnostic and treating modalities applied in nine patients with CD and EVFs, the clinical/epidemiological features of this clinical entity and to perform a systemic review of the literature, concerning the diagnosis and treatment of this complication. RESULTS: The medical records of eight men and one woman (mean age 42 ± 12 years) with EVFs were analyzed. The terminal ileum and the ileocecal region were affected in three and six cases, respectively. The most common symptoms were pneumaturia, fecaluria, fever, urinary urgency and abdominal pain. The diagnosis was suspected by abdominal CT scan and by indirect findings of bladder infection in cystoscopy. MRI with concurrent cystography set the diagnosis in three patients. Colonoscopy was not helpful. Conservative treatment, including administration of antibiotics and immunosuppressive agents in all patients and anti-TNF-a agent (infliximab) in six patients, was ineffective. Surgical treatment was applied in seven cases (77.8%), including fistula repair in all patients, drainage of coexistent intraabdominal abscess in two, small bowel resection in four and ileocecectomy in two cases. CONCLUSION: EFVs are uncommon but potentially dangerous complications of CD. Abdominal CT scan and cystoscopy are the most commonly used diagnostic modalities. Surgical treatment seems to be unavoidable in most cases, although medical treatment could also benefit a small cohort of patients.

Preoperative High Dose of Methylprednisolone Improves Early Postoperative Pulmonary Function, in Super-Obese Patients Undergoing Open Surgery; a Prospective, Comparative Study.

BACKGROUND: Surgery stimulates an intense systemic inflammatory response which might increase postoperative morbidity. Corticosteroids may reduce this inflammatory reaction. The purpose of this study was to investigate any possible effect on postoperative morbidity and recovery after administrating methylprednisolone in super-obese patients undergoing open surgery. METHODS: Sixty super-obese patients with BMI ≥50 kg/m2 (mean 57.48 ± 7.33), mean age of 39 ± 9 years, who underwent an open bariatric procedure, were enrolled. Thirty patients (group A) were allocated to a preoperative single dose of 30 mg/kg (ideal body weight) methylprednisolone versus placebo (group B, 30 patients). Endpoints included assessment of IL-6 and CRP; evaluation of postoperative pulmonary function, pain management, nausea, and vomiting; and documentation of postoperative complications. RESULTS: Significant improvement in spirometry parameters and arterial blood gas analysis, in the first and third postoperative days, was observed in the methylprednisolone group. IL-6 and CRP levels were significantly lower in that group. Administration of methylprednisolone was associated with less postoperative pain, nausea, and vomiting, with no statistical difference in septic complications. CONCLUSIONS: Preoperative administration of a single high dose of methylprednisolone in super-obese patients undergoing open surgery inhibits the inflammatory signaling cascade, lessens the systemic inflammatory response, and results in fewer pulmonary complications and better patient recovery.

Appendiceal mucocele and pseudomyxoma peritonei; the clinical boundaries of a subtle disease.

PATIENT: Male, 70 • Male, 84. FINAL DIAGNOSIS: Appendiceal mucocele and pseudomyxoma peritonei. SYMPTOMS: -. MEDICATION: -. CLINICAL PROCEDURE: -. SPECIALTY: Surgery. OBJECTIVE: Rare disease. BACKGROUND: Mucocele of the appendix is an uncommon cystic lesion characterized by distension of the appendiceal lumen with mucus. Most commonly, it is the result of epithelial proliferation, but it can also be caused by inflammation or obstruction of the appendix. When an underlying mucinous cystadenocarcinoma exists, spontaneous or iatrogenic rupture of the mucocele can lead to mucinous intraperitoneal ascites, a syndrome known as pseudomyxoma peritonei. CASE REPORT: We report 2 cases that represent the clinical extremities of this heterogeneous disease; an asymptomatic mucocele of the appendix in a 70-year-old female and a case of pseudomyxoma peritonei in an 84-year-old male. Subsequently, we review the current literature focusing to the optimal management of both conditions. CONCLUSIONS: Mucocele of the appendix is a rare disease, usually diagnosed on histopathologic examination of appendectomized specimens. Due to the existing potential for malignant transformation and pseudomyxoma peritonei caused by rupture of the mucocele, extensive preoperative evaluation and thorough intraoperative gastrointestinal and peritoneal examination is required.

Neutrophil Gelatinase-Associated Lipocalin as a Biomarker of Acute Kidney Injury in Patients with Morbid Obesity Who Underwent Bariatric Surgery.

INTRODUCTION: Neutrophil gelatinase-associated lipocalin (NGAL) has been identified as a biomarker of acute kidney injury (AKI) that could contribute to early diagnosis and effective management of AKI. The purpose of this study was to evaluate NGAL as a predictive marker of AKI in patients with clinically severe obesity (BMI >50) who underwent biliopancreatic diversion surgery. PATIENTS AND METHODS: We prospectively studied 23 patients with clinically severe obesity who underwent biliopancreatic bypass surgery. NGAL was measured using chemiluminescent microparticle immunoassay in three urine samples collected from each patient before surgery (first sample), 2-6 h after surgery (second sample) and on the first postoperative day (third sample). RESULTS: Renal function was evaluated using serum creatinine values, which were 0.91 ± 0.26 mg/dl before surgery, 0.87 ± 0.31 mg/dl immediately after surgery and 0.92 ± 0.62 mg/dl on the fifth postoperative day. During the immediate postoperative period, AKI was observed in 2 patients, one of whom required renal replacement therapy with hemodialysis. In both patients, urine NGAL increased within the first postoperative hours before the values of serum creatinine increased. CONCLUSION: Urine NGAL in patients with clinically severe obesity, which was surgically treated, might be a potential biomarker of early AKI detection. Further research is required in order to confirm these results observed in a small number of patients who developed postoperative AKI and make recommendations for predictive NGAL values in patients who underwent bariatric surgery.