Characterising oesophageal motility disorders by high-resolution impedance manometry in dermatomyositis patients.

OBJECTIVES: We studied high-resolution impedance manometry (HRiM) findings in dermatomyositis (DM) to detect oesophageal dysmotility, even in asymptomatic patients, and correlated the alterations to clinical and serological disease domains. METHODS: We performed a cross-sectional study of DM patients, enrolled between December 2021 and December 2022. All patients underwent rheumatological, laboratory and HRiM assessment. HRiM findings were compared with different clinical and serological profiles. RESULTS: The study population consisted of 15 DM patients (13 women and 2 men, age 54±15.2 years). The mean disease duration was 6.6 years. According to HRiM findings, three different groups of oesophageal disease severity were identified (in order of severity G0, G1 and G>1, 5 patients per group). G>1 group was significantly associated with MDA5 antibodies (80% vs. 20%, p<0.05). Interstitial lung disease (ILD) did not show any significant association with HRiM findings. However, a diffusing lung capacity for carbon oxide (DLCO) < 80% was present in 100% of G>1 (p<0.05). No associations between dysphagia, creatine kinase (CK) level, muscle weakness, skin, articular involvement and treatment were found. CONCLUSIONS: Oesophageal involvement is frequent and should be evaluated in the comprehensive work-up of DM. We used for the first time HRiM in DM, which proved to be an accurate and objective technique in assessing oesophageal disease, even in the subclinical stage. Interestingly, the MDA5-positive group had a higher burden of HRiM pathological findings, suggesting a greater severity of oesophageal involvement, often asymptomatic.

Fissurectomy versus lateral internal sphincterotomy in the treatment of chronic anal fissures: no advantages in terms of post-operative incontinence.

PURPOSE: The standard treatment for chronic anal fissures that have failed non-operative management is lateral internal sphincterotomy. Surgery can cause de novo incontinence. Fissurectomy has been proposed as a sphincter/saving procedure, especially in the presence of a deep posterior pouch with or without a crypt infection. This study investigated whether fissurectomy offers a benefit in terms of de novo post-operative incontinence. METHODS: Patients surgically managed with fissurectomy or lateral internal sphincterotomy for chronic anal fissures from 2013 to 2019 have been included. Healing rate, changes in continence and patient satisfaction were investigated at long-term follow-up. RESULTS: One hundred twenty patients (55 females, 65 males) were analysed: 29 patients underwent fissurectomy and 91 lateral internal sphincterotomy. Mean follow-up was 55 months [confidence interval (CI) 5-116 months]. Both techniques showed some rate of de novo post-operative incontinence (> +3 Vaizey score points): 8.9% lateral internal sphincterotomy, 17.8% fissurectomy (p = 0.338). The mean Vaizey score in these patients was 10.37 [standard deviation (sd) 6.3] after lateral internal sphincterotomy (LIS) and 5.4 (sd 2.3) after fissurectomy Healing rate was 97.8% in the lateral internal sphincterotomy group and 75.8% in the fissurectomy group (p = 0.001). In the lateral internal sphincterotomy group, patients with de novo post-op incontinence showed a statistically significant lower satisfaction rate (9.2 ± 1.57 versus 6.13 ± 3; p = 0.023) while no differences were present in the fissurectomy group (8.87 ± 1.69 versus 7.4 ± 1.14; p = 0.077). CONCLUSIONS: Lateral internal sphincterotomy is confirmed as the preferred technique in term of healing rate. Fissurectomy did not offer a lower rate of de novo post-operative incontinence, but resulted in lower Vaizey scores in patients in whom this occurred. Satisfaction was lower in patients suffering a de novo post-operative incontinence after lateral internal sphincterotomy.

Which Role for Hyperbaric Oxygen Therapy in the Treatment of Fournier's Gangrene? A Retrospective Study.

Purpose: In Fournier's gangrene, surgical debridement plus antimicrobial therapy is the mainstay of treatment but can cause a great loss of tissue. The disease needs long hospital stays and, despite all, has a high mortality rate. The aim of our study is to investigate if factors, such as hyperbaric therapy, can offer an improvement in prognosis. Methods: We retrospectively evaluated data on 23 consecutive patients admitted for Fournier's gangrene at the University Hospital "P. Giaccone" of Palermo from 2011 to 2018. Factors related to length of hospital stay and mortality were examined. Results: Mortality occurred in three patients (13.1%) and was correlated with the delay between admission and surgical operation [1.7 days (C.I. 0.9-3.5) in patients who survived vs. 6.8 days (C.I. 3.5-13.4) in patients who died (p = 0.001)]. Hospital stay was longer in patients treated with hyperbaric oxygen therapy [mean 11 (C.I. 0.50-21.89) vs. mean 25 (C.I. 18.02-31.97); p = 0.02] without an improvement in survival (p = 1.00). Conclusion: Our study proves that a delay in the treatment of patients with Fournier's gangrene has a correlation with the mortality rate, while the use of hyperbaric oxygen therapy seems to not improve the survival rate, increasing the hospital stay instead.

Fissurectomy and anoplasty in posterior normotensive chronic anal fissure.

PURPOSE: Anal Fissure (AF) is the second most frequent proctological disease in Italy. Chronic AF (CAF) most common located at the posterior anal commissure (CAPF). CAPF are thought to be associated with hypertonic internal anal sphincter (IAS) but manometric findings showed that a normotonic IAS is present in the 20-40%. Sphincterotomy is often recommended as treatment of choice for CAF independently from IAS tone; nevertheless, this approach appears less logical for CAF with normotonic IAS, as in those cases there's a higher risk of post-operative anal incontinence. The aim of this study is to evaluate the results of fissurectomy and anoplasty with V-Y cutaneous advancement flap, as treatment for patients suffering from CAPF without hypertonic IAS. METHODS: We enrolled 30 patients affected by CAPF without IAS hypertonia. All patients were followed up for 2 years after the surgical procedure, with evaluation of anal continence, recurrence rate and maximum resting pressure, maximum squeeze pressure, ultraslow wave activity. RESULTS: All patients healed within 40 days after surgery. We didn't observe any "de novo" post-operative anal incontinence cases. We reported 2 cases of recurrences, within 18 months from surgery, all healed after conservative therapy. We didn't record statistically significant differences in pre- and post-operative manometry findings. CONCLUSION: At 2 years after the surgical procedure we achieved good results, these evidences shows that sphincter preserving procedures are more suitable for CAPF without hypertonic IAS.

Early diagnosis of primary melanoma of caecum. Case report and review of the literature.

Malignant gastrointestinal melanoma is usually a metastatic lesion. We report the case of a 79-year-old female asymptomatic patient. Colonoscopy revealed one plane 15 mm pigmented lesion in the caecum. Neither CT scan of the abdomen nor right hemicolectomy revealed no metastatic disease. Histopathological examination of the surgical specimen was indicative of malignant melanoma.A set of additional enquires such as laboratory and imaging tests did not point out any suspicious lesions in the skin, eye, leptomeninges or other sites. Therefore, we made the diagnosis of primary colonic melanoma.The diagnosis of this disease is still a challange and often demanding for a multidisciplinary approach, involving the surgeon, onclogist and even immunotherapy or radiotherapy.

Safety and effectiveness of saving sphincter procedure in the treatment of chronic anal fissure in female patients.

INTRODUCTION: Lateral internal sphincterotomy (LIS) is still the approach of choice for the treatment of chronic anal fissure (CAF) regardless to the internal anal sphincter tone but it is burdened by high risk post-operative faecal incontinence (FI). In female patient there are some anatomical and functional differences of the sphinteric system which make them more at risk of FI and vaginal birth could cause sphinteric lesions affecting the anal continence function. The aim of our study is to evaluate the results of saving sphincter procedure as treatment for female patients affected by CAF. METHODS: We studied 110 female patients affected by CAF undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement associating pharmacological sphincterotomy in patients with hypertonic IAS. The follow up was at least for 2 years. The goals were patient's complete healing, the evaluation of FI, recurrence rate and manometry parameters. RESULTS: All wounds healed within 40 days after surgery. We recorded 8 cases of recurrences 6 healed with medical therapy and 2 with dilatation. We recorded 2 "de novo" temporary and low grade post-operative cases of FI. Post-operative value of MRP were unmodified in patient with normotonic IAS but significantly lower at 12 months follow up as compared with the pre-operative ones in patients with hypertonic IAS; after 24 months from surgery MRP values were within the normal range. CONCLUSION: The fissurectomy and anoplasty with V-Y cutaneous flap alone or in association with a pharmacological sphincterotomy in patients with hypertonic IAS may represent an effective approach for the treatment of CAF in female patients.

Lateral Internal sphincterotomy is still crucial to heal hypertonic chronic anal fissure and normalize the internal anal sphincter tone? Is V-en Y plastic a valuable alternative?

INTRODUCTION: The role of augmented internal anal sphincter (IAS) tone in the genesis of chronic anal fissure (CAF) is still unclear. Lateral internal sphincterotomy (LIS) is the most employed surgical procedure, aiming to reduce the IAS tone leaving a permanent anatomical alteration and it is burdened by high risk post-operative anal incontinence (AI). The aim of this work was to evaluate if the pre-operative manometric alterations of CAFs with hypertonic IAS would normalize after sphincter preserving surgical procedure. METHODS: We enrolled 108 consecutive patients affected by idiopathic and non-recurrent CAF undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement and pharmacological sphincterotomy, matched with 54 healthy subject in a 1 to 2 ratio, and followed up for at least for 2 years. The goals were patient's complete healing, the evaluation of AI, recurrence rate and manometry parameters. RESULTS: All wounds healed within 40 days after surgery. We recorded 7 cases of recurrences healed with medical therapy. We recorded 3 "de novo" post-operative cases of AI all temporary and low grade. Pre-operative values of maximum resting pressure (MRP) and detection of ultraslow wave activity (USWA) were significantly higher than in the healthy control group, but both come back to be similar to those recorded in healthy subject after 24 months from the surgery. CONCLUSION: The high healing rate without post-operative "de novo" AI cases with the normalization of manometric parameters suggest that fissurectomy and anoplasty with V-Y cutaneous advancement flap and pharmacological sphincterotomy is an adequate procedure for the treatment of CAF with IAS hypertonia. KEY WORDS: Anal fissure, Anoplasty, Fissurectomy, Proctology, Sphincterotomy.

A Stepwise Proposal for Low-Grade Hemorrhoidal Disease: Injection Sclerotherapy as a First-Line Treatment and Rubber Band Ligation for Persistent Relapses.

Outpatient treatments are actually the techniques of choice in the management of low-grade hemorrhoidal disease. Among these, rubber band ligation (RBL) and injection sclerotherapy (IS) are the most frequently performed. Both techniques are used, without one having been determined to be superior over the other. We analyzed the studies that compare these two techniques in terms of efficacy and safety in order to offer a proposal for treatment choice. RBL seems to be most efficient in terms of symptom resolution for second-degree hemorrhoidal disease and equal or superior for treatment of third-degree disease. However, IS offers lower rates of severe post-operative pain and minor complications. Since outpatient treatments are offered to patients as painless options that allow a prompt recovery, we propose a stepwise protocol using 3% polidocanol or aluminum potassium sulfate and tannic acid IS as the first treatment option, as it has less complications, followed by RBL in cases of relapse.

Surgical Sphincter Saving Approach and Topical Nifedipine for Chronic Anal Fissure with Hypertonic Internal Anal Sphincter.

PURPOSE: The role of augmented internal anal sphincter (IAS) tone in the genesis of posterior chronic anal fissure (CAPF) is still unknown. Lateral internal sphincterotomy is the most employed surgical procedure, nevertheless it is burdened by high risk post-operative anal incontinence. The aim of our study is to evaluate results of sphincter saving procedure with post-operative pharmacological sphincterotomy for patients affected by CAPF with IAS hypertonia. Methods: We enrolled 30 patients, undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement; all patients received topical administration of nifedipine 0.3% and lidocaine 1.5% ointment-based therapy before and for 15 days after surgery. The primary goal was patient's complete healing and the evaluation of incontinence and recurrence rate; the secondary goal included the evaluation of manometry parameters, symptom relief and complications related to nifedipine and lidocaine administration. Results: All wounds healed within 40 days after surgery. We didn't observe any de novo postoperative anal incontinence case. We reported 2 cases of recurrences, healed after conservative therapy. We didn't report any local complications related to the administration of the ointment therapy; with whom all patients reported a good compliance. Conclusions: Fissurectomy and anoplasty with V-Y cutaneous advancement flap and topical administration of nifedipine and lidocaine, is an effective treatment for CAPF with IAS hypertonia.

Long term outcomes of fissurectomy and anoplasty for chronic anterior anal fissure without hypertonia: low recurrences and continence conservation.

INTRODUCTION: Aetiopathogenesis of Chronic Anal Anterior Fissure (CAAF) remains poorly understood. Some anatomical, clinical and functional features suggest that pathophysiology may be linked to a reduced anal canal pressure. LIS appear illogical as a treatment for CAAF and the employ of techniques aiming to save the integrity of the sphincterial system appears more sensible. The aim of this study was to evaluate 5 years results of fissurectomy and anoplasty with cutaneous V-Y advancement flap in patients affected by CAAF without IAS hypertonia. METHODS: We enrolled 20 women, affected by idiopathic and non-recurrent CAAF without hypertonic IAS. All patients were followed up for 5 years after surgery with evaluation of anal continence, short and long term post-operative complications, recurrence rate. RESULTS: At 5 years follow up we did not record any new case of anal incontinence and the pre-existing ones haven't worsened. We observed 2 recurrences, which occurred within 2 years after surgery and healed after medical therapy. The manometric values were similar than those recorded prior to surgery. CONCLUSION: Our study suggests that the procedure performed allows us to preserve anal continence and avoid worsening of its pre-existing alteration. KEY WORDS: Anal canal, Anoplasty, Fissure, Fissurectomy, Proctology, Sphincterotomy.

Skip metastases to lateral cervical lymph nodes in differentiated thyroid cancer: a systematic review.

Papillary thyroid carcinoma is a slow-growing cancer with a generally good prognosis that sometimes have an aggressive behaviour. Metastases to neck lymph nodes is the first step of the diffusion. The central neck compartment is involved most commonly. The ipsilateral lateral neck compartments are usually involved afterwards, and the involvement of the contralateral one is considered a quite rare occurrence. In more rare cases, metastases to lateral neck compartment without central lymph node metastasis (so called "skip metastases") could be observed. Aim of this literature review study is to analyse the average incidence, pattern and risk factors of this occurrence.This study was performed according to PRISMA criteria. A final selection of 13 articles published in English language from 1997 to 2017 was performed. Any research article, review or meta-analysis was taken into consideration. Research was expanded considering the related references of articles.The incidence of skip metastases ranged from 1.6 to 21.8%. Risk factors such as age > 45 years, size < 5 mm and tumor located in the upper pole or isthmus of thyroid gland were found.Due to the frequency of skip metastases in thyroid cancer, a careful preoperative examination of lateral lymph nodes should be necessary.

Clinical and Functional Outcome After Abdominal Wall Incisional Hernia Repair: Evaluation of Quality-of-Life Improvement and Comparison of Assessment Scales.

BACKGROUND: Hernias severely impact patient quality of life (QoL), and 80% of patients need surgical operation. The primary outcome of the study is to assess improvements in balance, posture and deambulation after abdominal hernia repair. Moreover, the study investigated the improvement in the postoperative QoL. METHODS: Patients operated at the Policlinico "Paolo Giaccone" at Palermo University Hospital between June 2015 and June 2017 were identified in a prospective database. The functional outcome measures and QoL assessment scales used were numeric rating scale for pain, performance-oriented mobility assessment (POMA) scale, Quebec back pain disability scale, center of gravity (barycenter) variation evaluation, Short-Form (36) Health Survey (SF-36 test), sit-up test and Activities Assessment Scale (AAS). The timepoints at which the parameters listed were assessed for the study were 1 week before the surgical operation and 6 months later. RESULTS: The POMA scale showed a significant improvement, with an overall preoperative score of (mean; SD) 18.80 ± 2.17 and a postoperative score of 23.56 ± 2.24 with a p < 0.003. The improvement of the barycenter was significant with p = 0.03 and 0.01 for the right and left inferior limbs, respectively. Finally, common daily activities reported by the SF-36 test and by the AAS were significantly improved with a reported p of ≤0.04 for 5 of eight items and ≤0.002 for all items, respectively. CONCLUSIONS: The improvement in such physical measures proves the importance of abdominal wall restoration to recover functional activity in the muscle-skeletal complex balance, gait and movement performance.

The abdominal wall hernia in cirrhotic patients: a historical challenge.

Background: The incidence rate of abdominal wall hernia is 20-40% in cirrhotic patients. A surgical approach was originally performed only if complication signs and symptoms occurred. Several recent studies have demonstrated the usefulness of elective surgery. During recent decades, the indications for surgical timing have changed. Methods: Cirrhotic patients with abdominal hernia who underwent surgical operation for abdominal wall hernia repair at the Policlinico "Paolo Giaccone" at Palermo University Hospital between January 2010 and September 2016 were identified in a prospective database, and the data collected were retrospectively reviewed; patients' medical and surgical records were collected from charts and surgical and intensive care unit (ICU) registries. Postoperative morbidity was determined through the Clavien-Dindo classification. Cirrhosis severity was estimated by the Child-Pugh-Turcotte (CPT) score and MELD (model of end-stage liver disease) score. Postoperative mortality was considered up to 30 days after surgery. A follow-up period of at least 1 year was used to evaluate hernia recurrence. Results: The univariate and multivariate analyses demonstrated the unique independent risk factors for the development of postsurgical morbidity (emergency surgery (OR 6.42; p 0.023), CPT class C (OR 3.72; p 0.041), American Society of Anesthesiologists (ASA) score ≥ 3 (OR 4.72; p 0.012) and MELD ≥ 20 (OR 5.64; p 0.009)) and postsurgical mortality (emergency surgery (OR 10.32; p 0.021), CPT class C (OR 5.52; p 0.014), ASA score ≥ 3 (OR 8.65; p 0.018), MELD ≥ 20 (OR 2.15; p 0.02)). Conclusions: Concerning abdominal wall hernia repair in cirrhotic patients, the worst outcome is associated with emergency surgery and with uncontrolled disease. The correct timing of the surgical operation is elective surgery after ascites drainage and albumin/electrolyte serum level and coagulation alteration correction.

Swallowing disorders after thyroidectomy: What we know and where we are. A systematic review.

INTRODUCTION: Dysphagia and hoarseness are possible complications that can be observed in patients undergoing thyroidectomy or other neck surgery procedures. These complaints are usually related to superior and inferior laryngeal nerves dysfunction, but these can appear even after uncomplicated surgical procedure. METHODS: We reviewed the current literature available on MEDLINE database, concerning the swallowing disorders appearing after the thyroidectomy. The articles included in the review reported pathophysiology and diagnostic concerns. RESULTS: Twenty articles were selected for inclusion in the review. Depends on the possible causes of the difficulty swallowing (related to nerve damage or appearing after uncomplicated thyroidectomy), different types of diagnostic procedures could be used to study patient discomfort, as well as intraoperative nerve monitoring, fiber optic laryngoscopy, endoscopy, pH monitoring, esophageal manometry and videofluorography. Among all these procedures, videofluorography is considered the gold standard to evaluate the entire swallowing process, since that allows a real-time study of all the three phases of swallowing: oral phase, pharyngeal phase and esophageal phase. CONCLUSION: The diagnostic procedures described can help to identify the mechanisms involved in swallowing disorders, with the aim to choose the best therapeutic option. More studies are needed for understanding the causes of the dysphagia appearing after thyroidectomy.

The prevalence of post-thyroidectomy chronic asthenia: a prospective cohort study.

PURPOSE: Chronic asthenia (CA) is complained by some patients that have undergone thyroid surgery. We evaluate its impact in patients undergoing unilateral or bilateral thyroidectomy, the trend during a 1-year follow-up, and the possible risk factors. METHODS: A prospective, cohort study was carried out on 263 patients scheduled for thyroidectomy from 2012 and 2014. Exclusion criteria were as follows: Graves' disease, malignancies requiring radioiodine therapy, post-surgical hypoparathyroidism, laryngeal nerve palsy, abnormal pre- and post-operative thyroid hormone levels, and BMI outside the normal range. Demographics; smoking and alcoholism addiction; cardiac, pulmonary, renal, and hepatic failure; diabetes; anxiety; and depression were recorded. The Brief Fatigue Inventory (BFI) was used to evaluate CA and its possible association with these comorbidities 6 and 12 months after thyroidectomy. RESULTS: One hundred seventy-seven patients underwent total thyroidectomy (TT), 54 hemithyroidectomy (HT). Thirty-two patients were not recorded because of the onset of exclusion criteria. In the 6 months after thyroidectomy, in the TT group, 64 patients (36.16%) reported an impairment in the BFI score and only 1 in the TL group. The mean BFI score changed from 1.663(±1.191) to 2.16 (±11.148) in the TT group, from 1.584 (±1.371) to 1.171 (±1.093) in the TL group (p < 0.001). No further significant variations in BFI were reported 1 year after surgery. CONCLUSIONS: CA worsened after TT, but not after HT. Apart from operative procedure itself, no other risk factor was found be significantly associated with post-thyroidectomy asthenia. Further investigation is needed to determine the causes of CA.

Role of prophylactic central neck dissection in cN0-papillary thyroid carcinoma: results from a high-prevalence area.

BACKGROUND: Prophylactic, compartment-oriented central neck dissection (CND) for cN0 papillary thyroid carcinoma (PTC) is not widely practiced. We examined our results with this surgical approach. METHODS: A cohort of 158 patients operated on for the classical variant of PTC at a follow-up of 1-22 years (mean: 6.6) were enrolled. The patients with a preoperative diagnosis of cN0 PTC (group A, 59 patients) underwent total thyroidectomy (TT) + CND. In the patients with incidental postoperative diagnosis of malignancy (group B, 99 patients) a TT alone was performed. RESULTS: Ninety-six T1, 36 T2, 26 T3/T4 PTC patients were enrolled. The overall biochemical/scintigraphic recurrence rate (15 patients, 9.49%), was significantly higher in group B. Disease-free survival and need for postoperative radioiodine ablative treatment were more favorable in group A (P<0.05; P<0.001, respectively). The median radioiodine ablative treatment in the T2 cluster alone was lower in group A (P<0.001). The morbidity rate was similar in both groups. CONCLUSION: Considering the acceptable morbidity, prophylactic CND seems to be advantageous in terms of recurrence rate and need for radioiodine treatment in this variant of PTC, at least in T2 or more advanced stages. The indolent behavior of PTC does not allow for reliable prognostic evaluations.

Recurrent cystic lymphangioma of the neck. Case report.

UNLABELLED: Cystic lymphangioma is a rare benign tumor commonly located in the head or neck. Approximately 100 adult cases have been reported in the literature. The etiopathogenesis is unclear, though trauma has been suggested as one of the possible causes. CASE REPORT: We report a case of recurrent cystic lymphangioma arising in an adult who had been successfully treated in our department, leading us to review the literature for a critical examination of our therapeutic choices and the pathological, clinical and therapeutic aspects. We performed a dissection of the cyst respecting anatomical structures.Three days after the surgery, the patient showed a recurrence under the previous site of the excision, We then decided to place a suction drainage under local anesthesia, The suction drainage was removed 25 days later.The post-operative course of the patient showed no signs of recurrence for twenty-four months. DISCUSSION: Complete surgical excision is the treatment of choice in symptomatic patients. In our experience, postoperative suction drainage improved the outcome. Some authors have come out in favor of experimental, non-surgical methods, such as percutaneous sclerotherapy, which they claim offer the most promising results. CONCLUSIONS: In our experience, totally excision of the mass was the treatment of choice but, placing just one suction drainage for weeks for new recurrence resulted in a surprising outcome. In fact, recurrence usually appears within the first nine months in about 10-15% of patients.

Predictive factors of mortality in patients with acute mesenteric ischemia. A retrospective study.

AIM: The aim of this retrospective study was to evaluate the impact of some risk factors on mortality in patients with Acute mesenteric ischemia (AMI). MATERIALS AND METHODS: From September 2003 to August 2011, 200 patients were operated on for bowel infarction at our unit: 149 were included in the study. For each patient, socio-demographic (gender and age) and clinical data (extent of necrosis, predisposing factors, WBC, LDH, comorbidities) were collected from patients' clinical records. RESULTS: Of the 149 patients who underwent surgery, 57 (38.3%) died. A significantly higher mortality was associated with older age (79.9 versus 74.2 years, p < 0.01), higher LDH serum levels (695 versus 636 UI/L, p < 0.01), higher WBC (25.1 versus 22.5 X 103/mm3; p < 0.01), and extent of necrosis (p< 0.01). Otherwise, there was no correlation between comorbidities and mortality. Finally, multivariate analysis confirmed the significantly higher risk of death in patients with right colon and massive small bowel infarction (adjOR= 3.58; 95% CI=1.36-9.42) and intestinal perforation (adjOR=31.1; 95% CI=2.45-395.7). DISCUSSION: The results of our study suggest that the contribution of laboratory tests is limited, even if increased indexes of necrosis (such as LDH) associated with neutrophilic leukocytosis and metabolic acidosis, may help in defining diagnosis/ prognosis, though with low accuracy. CONCLUSIONS: The extent of necrosis and diagnostic delay seem to be the most important prognostic factors even after adjusting for confounding due to age, presence of comorbidities, and laboratory tests (LDH and WBC). KEY WORDS: Acute mesenteric ischemia, Mortality, Predictive factors.

KPC - 3 Klebsiella pneumoniae ST258 clone infection in postoperative abdominal surgery patients in an intensive care setting: analysis of a case series of 30 patients.

BACKGROUND: Abdominal surgery carries significant morbidity and mortality, which is in turn associated with an enormous use of healthcare resources. We describe the clinical course of 30 Intensive Care Unit (ICU) patients who underwent abdominal surgery and showed severe infections caused by Klebsiella pneumoniae sequence type (ST) 258 producing K. pneumoniae carbapenemase (KPC-Kp). The aim was to evaluate risk factors for mortality and the impact of a combination therapy of colistin plus recommended regimen or higher dosage of tigecycline. METHODS: A prospective assessment of severe monomicrobial KPC-Kp infections occurring after open abdominal surgery carried out from August 2011 to August 2012 in the same hospital by different surgical teams is presented. Clinical and surgical characteristics, microbiological and surveillance data, factors associated with mortality and treatment regimens were analyzed. A combination regimen of colistin with tigecycline was used. A high dose of tigecycline was administered according to intra-abdominal abscess severity and MICs for tigecycline. RESULTS: The mean age of the patients was 56.6 ± 15 and their APACHE score on admission averaged 22.72. Twenty out of 30 patients came from the surgical emergency unit. Fifteen patients showed intra-abdominal abscess, eight anastomotic leakage, four surgical site infection (SSI) and three peritonitis. The overall crude ICU mortality rate was 40% (12 out of 30 patients). Twelve of the 30 patients were started on a combination treatment of high-dose tigecycline and intravenous colistin. A significantly lower mortality rate was observed among those patients compared to patients treated with approved dose of tigecycline plus colistin. No adverse events were reported with high doses of tigecycline. CONCLUSIONS: Critically-ill surgical patients are prone to severe post-surgical infectious complications caused by KPC-Kp. Timely microbiological diagnosis and optimizing antibiotic dosing regimens are essential to prevent worse outcomes. Further studies and well-controlled clinical trials are needed to define the optimal treatment of infections by KPC-Kp and, more generally, carbapenem-resistant bacteria.

Esophageal motility changes after thyroidectomy; possible associations with postoperative voice and swallowing disorders: preliminary results.

OBJECTIVE: Swallowing and voice impairment are common after thyroidectomy. We evaluated short-term functional changes in esophageal motility in a series of patients who had undergone total thyroidectomy. Several studies have investigated these symptoms by means of interviews or questionnaires. STUDY DESIGN: Prospective study. SETTING: Academic research. MATERIALS AND METHODS: Thirty-six consenting patients were prospectively recruited. Eligibility criteria were thyroid volume ≤ 60 mL, benign disease, and age between 18 and 65 years. Exclusion criteria were previous neck surgery, severe thyroiditis, hyperthyroidism, and pre- or postoperative vocal cord palsy. Voice impairment score, swallowing impairment score, lower esophageal sphincter pressure, esophageal motility, upper esophageal pressure, and coordination were evaluated preoperatively and 30 to 45 days after surgery. RESULTS: Postoperative swallowing impairment (appearance or worsening of dysphagia) was found in 20% of patients and voice impairment in more than 30%. Both preoperative and postoperative esophageal motility were similar. All patients showed an average decrease of 25% in upper esophageal pressure, although the pressure was within normal range. Swallowing alterations were associated with upper esophageal incoordination (P < .03), and proximal acid reflux was significantly associated with voice impairment (P < .02). CONCLUSION: After uncomplicated thyroidectomy, decreased upper esophageal pressure may explain both pharyngeal (dysphagia) and laryngeal (vocal impairment) exposure to acid. In the future, proton pump inhibitor therapy protocols should be evaluated.