Acute acalculous cholecystitis on a COVID-19 patient: a case report.

INTRODUCTION: We report an extremely rare case of acute acalculous cholecystitis on a COVID-19 patient. In our knowledge, this is the first report of laparoscopic cholecystectomy performed on a COVID-19 patient. PRESENTATION OF CASE: A COVID-19 patient was diagnosed with acute acalculous cholecystitis and a multidisciplinary team decided to perform a percutaneous transhepatic biliary drainage (PTBD) as the first treatment. SARS-CoV-2 RNA was not found in the bile fluid. Because of deterioration of the patient's clinical conditions, laparoscopic cholecystectomy had to be performed and since the gallbladder was gangrenous, the severe inflammation made surgery difficult to perform. DISCUSSION: Acalculous cholecystitis was related with mechanical ventilation and prolonged total parenteral nutrition, in this case the gangrenous histopathology pattern and the gallbladder wall ischemia was probably caused by vascular insufficiency secondary to severe acute respiratory distress syndrome of COVID-19 pneumonia. The percutaneous transhepatic gallbladder drainage (PTBD) was performed according to Tokyo Guidelines because of high surgical risk. Laparoscopic cholecystectomy was next performed due to no clinical improvement. The absence of viral RNA in the bile highlights that SARS-CoV-2 is not eliminated with the bile while it probably infects small intestinal enterocytes which is responsible of gastrointestinal symptoms such as anorexia, nausea, vomiting, and diarrhoea. CONCLUSIONS: Although the lack of evidence and guidelines about the management of patient with acute cholecystitis during COVID-19 pandemic, laparoscopic cholecystectomy, at most preceded by PTGBD on high surgical risk patients, remains the gold standard for the treatment of acute cholecystitis on COVID-19 patients.

[Learning curve and early complications of totally implantable venous access devices: is tutoring the solution for the problem?]. / La learning curve e le complicanze immediate dei sistemi totalmente impiantabili venosi: il tutoring come soluzione del problema?

During the last years operators implanting totally implantable venous access devices (TIVADs), type of access, and kind of complications are changed. Aim of this work is to evaluate the incidence of early complications during the learning curve of residents in surgery or inexperienced surgeons, besides considering the tutoring to evaluate its rule to prevent early complications. TIVADs, implanted by residents in surgery or by inexperienced surgeons in the Department of Surgical Science Organ Transplantation and Advanced Technologies of University of Catania from January 1995 to October 2003, have been considered for the present study. Age and sex of the patients, indication, type of surgical access and early complications of the TIVADs have been considered. Early complications are those complications that occur within 30 day after the implant. Ninety-five TIVADs were implanted by surgical approach in 95 patients: 58 males (61%) and 37 females (39%), with a mean age of 55 years (range 31-79). Inexperienced surgeons performed 40 implants (42%) instead resident in surgery implanted 55 TIVADs (58%). The migration out of the vein of a catheter 20 days after the operation was the only complication recorded. TIVADs implant by cut-down technique represent the way to avoid early complications. The learning curve is short and the tutoring is limited at the first phase.

[Cutaneous ascites as complication of the placement of a totally implantable arterial system]. / Filtrazione ascitica cutanea come complicanza del posizionamento di un sistema totalmente impiantabile arterioso.

The Authors report the case of a patient with intrahepatic colangiocarcinoma, operated on for totally implantable arterial device (TIAD) implant in view of hepatic chemotherapy. The postoperative course was characterized by cutaneous drainage of ascites fluid from the wound of the TIAD implant. Its aetiology and therapy are discussed.

[Importance of nursing in the prevention of complications of totally implantable venous access devices]. / Importanza del nursing nella prevenzione delle complicanze dei sistemi totalmente impiantabili.

The Authors report a case of a patient submitted to chemotherapy that has a complication of its totally implantable venous access device (TIVAD) due to incorrect nursing. The symptoms related to the extravasation of drugs were due to the lateral lesions of the catheter with Huber needle. After X-ray examination the therapy was ablation of the non-functioning device and implant of a new TIVAD. The Authors conclude about careful nursing of the TIVAD in order to avoid further psychological problems in cancer patients.

Laparoscopic resection of an abdominal wall desmoid using a modified suture traction technique: the "marionette trick".

Desmoids are rare mesenchimal tumors that may originate also inside the abdomen or in the abdominal wall. These tumors are biologically characterized by a tendency to local growth, and only rarely are they able to develop distant metastases. Surgical excision usually is the best treatment with a chance of a cure. In the few reports on intraabdominal or abdominal wall desmoids, open surgery always was performed. The first case of successful laparoscopic resection of a symptomatic anterior wall desmoid tumor with intraabdominal growth is reported. During the procedure, it was difficult to mobilize and grasp the mass using the common laparoscopic instruments, but with the help of the "marionette trick," modified suture traction technique, the tumor could be removed easily using only three trocars. With four traction sutures minimizing the wall trauma, the trick made it possible to mobilize the mass in at least, seven directions, according to the principles of physical forces and vectors. This simple trick can be helpful for other common laparoscopic procedures, avoiding the insertion of sometimes ineffective instruments through more traumatic trocars.

Efficacy and safety of elective laparoscopic cholecystectomy in elderly: a case-controlled comparison with the open approach.

BACKGROUND: Minimally invasive laparoscopic surgery is the method of choice for the surgical treatment of gallbladder disease. However, surgery of the biliary tract in the elderly is often associated with high morbidity and mortality. PATIENTS AND METHOD: To evaluate the efficacy and safety of the laparoscopic cholecystectomy in the elderly with symptomatic, uncomplicated gallbladder disease, we retrospectively compared the records of 24 consecutive patients over 70 years of age with symptomatic uncomplicated gallbladder disease, who underwent elective laparoscopic cholecystectomy, with a similar cohort of patients who underwent elective open cholecystectomy for the same indications. RESULTS: In the laparoscopic group we found a significantly low incidence of postoperative complications, low analgesics and antibiotics administration, rapid recovery, short length of stay and considerable cost savings. CONCLUSION: We conclude that elective laparoscopic cholecystectomy in elderly with uncomplicated gallbladder disease is safe and effective and we suggest that it may become the surgical procedure of choice.

Extravascular migration of the catheter. A rare complication of the totally implantable venous device.

Since the first report of TIVD implantation, many authors have published immediate and post-operative complications. The Authors report the first case in which the catheter, implanted via the cephalic vein by cutdown technique, has migrated completely out of the vein. In order to avoid extravascular migration, during the surgical procedure, the catheter should be fixed at the vein with nonabsorbable sutures, taking care to avoid narrowing the catheter lumen. This case report discusses the possibility of catheter migration when a TIVD fails to function properly and considers how to avoid more disastrous effects.

Totally implantable venous access devices implanted surgically: a retrospective study on early and late complications.

BACKGROUND: The techniques used for the implantation of totally implantable venous access devices (TIVADs) are the percutaneous approach and surgical cutdown; however, the choice is still controversial. HYPOTHESIS: The surgical cutdown approach may be beneficial to reduce the rate of complications. DESIGN: Retrospective review. SETTING: A university hospital and a tertiary referral center. PATIENTS: Patients undergoing a TIVAD implant at the First Surgical Clinic of the University of Catania in Catania, Italy, between January 1995 and December 1999, were considered for the study. All of the devices were implanted in an operating room under fluoroscopic control. The vein of choice was the cephalic vein. When the cephalic vein was not suitable for implantation, the external jugular vein or the axillary vein and its branches were used. The percutaneous approach to the subclavian vein or internal jugular vein was considered a last resort to implant a catheter. RESULTS: During the study period, 346 TIVADs were implanted in 344 patients. The procedure was performed with local anesthesia in 341 cases (98.5%), and only 2 patients (0.6%) required sedation for psychological reasons. Three patients (0.9%) had their TIVAD placed during a laparotomy. In 326 patients (94.2%), the devices were implanted in the cephalic vein. In the remaining cases, other veins were used with surgical cutdown. The mean time for the procedure was 15 minutes. Percutaneous access was never used, and no early mechanical complications were recorded. Only 6 patients (1.8%) in our study group had late complications (1 case of migration of the catheter, 2 cases of infection, and 3 cases of withdrawal occlusion). The catheter life ranged from 6 to 1487 days (mean time, 348 days). CONCLUSION: Our results confirm the safety, speed, and low cost of the open cutdown technique. This surgical procedure avoids both early and late complications that frequently occur with percutaneous access. Surgical cutdown should be considered the technique of choice to implant the TIVAD, especially in cancer patients.

Chronic liver herniation through a right Bochdalek hernia with acute onset in adulthood.

Congenital right diaphragmatic hernia of Bochdalek rarely occurs in adults and usually is asymptomatic. We report a right Bochdalek hernia with chronic liver herniation and intestinal malrotation in a 55-year old woman who presented with acute intestinal occlusion. The diagnosis required definitive confirmation by CT scan. With impending strangulation, emergency surgery through a thoracoabdominal approach resulted in an easy hernia repair and reduced the technical difficulties due to the intestinal malrotation.

Totally implantable venous access device inserted during major abdominal operations for cancer. A new technique.

Totally implantable venous access devices are usually implanted by surgical cut-down technique or by percutaneous approach, after a first surgical procedure. The authors describe a new surgical approach utilizing the right gonadal vein or the vena cava for totally implantable venous access device placement in patients submitted to major digestive surgical procedures for tumors. This new surgical approach allows one to avoid a second operative procedure.

[Characterization and prognostic value of colorectal adenomas with molecular genetic markers]. / Caratterizzazione e valore prognostico degli adenomi colorettali mediante marcatori genetici molecolari.

AIM: The study analyses the expression of DNA-ploidy, ki-67, PCNA and p-53 and their role as potential markers of the development of colorectal adenomas. METHODS: 34 adenomas of the large intestine were analysed using endoscopic exeresis in 15 males and 13 females with a mean age of 64 years (range 42-80). Flow cytometric analysis was carried out to calculate the DNA-index and immunohistochemical tests were used to evaluate ki-67, PCNA and p-53. Statistical analysis was based on chi 2 test and Student's "t"-test. RESULTS: The DNA index was not statistically correlated with the histotype and grading. Ki-67 was highly positive in 5 adenomas, 2 aneuploids and 3 diploids, but did not show a clear relationship with other growth parameters. On the contrary, p-53 was statistically correlated with the more advanced degenerative state of adenomas, being pathological in 6 cases (30%), all with marked aneuploidy (p < 0.02) and severe dysplasia (p < 0.004). PCNA, which was also pathological (> 40%) in 4 (23.5%) aneuploid adenomas with severe dysplasia (2 villous and 2 tubulo-villous), appeared to be significantly correlated with the DNA index (p < 0.005), showing a proliferative index of exceptional clinical importance. CONCLUSIONS: The results of this study show that p-53 and PCNA are two parameters that contribute to the definition of the degenerative risk and allow patients to be selected for constant monitoring, although additional follow-up data are essential to enable the clinical verification of these results.

Catheter fracture and cardiac migration: a rare complication of totally implantable venous devices.

Totally implantable venous device (TIVD) are widely used for the treatment of patients requiring long-term chemotherapy, total parenteral nutrition and fluid replacement. Until today, many kinds of complications have been reported in the literature. We report an unusual case of catheter fracture as a consequence of pinchoff syndrome, and discuss the potential methods to avoid this complication and its evolution.

[Ileal endometriosis. A clinical case and a review of the literature]. / L'endometriosi dell'ileo. Caso clinico e revisione della letteratura.

Ileal localization of intestinal endometriosis is not extremely rare, but there are always problems related to the preoperative diagnosis. Symptoms of intestinal endometriosis offer often problems to the surgeon in the differential diagnosis with many more pregnant illnesses like appendicitis, diverticulitis, inflammatory bowel diseases and abdominal neoplasms. The authors report a case of endometriosis of the ileum clinically mimicking Crohn's disease. Crohn's disease of the ileum is the most frequently reported illness that is considered in the differential diagnosis. The review of the literature shows that a correct preoperative diagnosis of endometriosis of the ileum is very seldom done. All common diagnostic tools are not able to resolve diagnostic doubts. Also during explorative surgery the diagnosis of endometriosis is not easy. The authors conclude that endometriosis of the ileum has to be more often considered as possible cause of common intestinal symptoms mimicking inflammatory bowel disease and that this illness induces to reevaluate the importance for a correct diagnosis of an accurate clinical history.

Oesophageal perforation after sclerotherapy. Description of a case.

Surgery is considered mandatory for major oesophageal perforations but the operative risk in cirrhotic patients is very high. The best treatment of these perforations is unknown as these have been always analyzed together with all other kinds of oesophageal perforations. A case is reported of spontaneous healing of severe postsclerosal perforation in an aged cirrhotic patient treated conservatively who otherwise should have been treated surgically. Conclusions are that due to the rarity and the cirrhosis, the common guidelines for the treatment of major esophageal perforations are not to be automatically extended to these perforations as postsclerosal perforation is clinically particular, etiologically and prognostically different than all other oesophageal perforations. Conservative but active treatment is to be tried first also with major postsclerosal oesophageal perforations.

[Difficulties in defining and diagnosing gastroesophageal reflux: practical implications in surgery]. / Difficoltà di definizione e di diagnosi della malattia da reflusso gastro esofageo: risvolti pratici in chirurgia.

Today, it is difficult to set a correct definition and diagnosis of gastroesophageal reflux disease. The attempt to define it on the basis of "typical" symptoms, like heartburn and regurgitation, or "atypical" symptoms, like chronic cough, asthma, hoarseness and thoracic pain, or on the basis of endoscopic esophagitis presents notable difficulties. Moreover, the problem of a correct definition is tightly tied up to the ability to set a correct and early diagnosis. There are many diagnostics tools, but none of them is the golden standard. Today, the trend is to emphasize the role of the 24-hour pH-monitoring in diagnosing the reflux in those symptomatic patients with no visible esophagitis. However, its limit is to underline only the acid, not the duodenogastric alkaline reflux, which is also very important in the genesis of the inflammatory esophageal lesions. The esophageal manometry, however, evaluates only the mechanical state of the lower esophageal sphincter and the peristaltic function of the esophageal body but does not provide any direct information about the exposure of the esophagus to the gastric juice. The aim of this study is to analyze the problems concerning the definition and the diagnosis of the gastroesophageal reflux disease with particular attention to the practical implications on the common surgical practice, and to review some solutions reported in the literature for the difficult clinical approach to the patient with this pathology.

[Evolution of the technique and indications of mini-invasive surgery of cholelithiasis]. / L'evoluzione della tecnica e delle indicazioni nella chirurgia mininvasiva della colelitiasi.

BACKGROUND: A review of the experience with laparoscopic cholecystectomy to evaluate the impact of the efficacy, safety, and complications on the learning curve. STUDY DESIGN: Retrospective study. METHODS: Between 1993 and 1998, 415 patients, 123 males and 292 females, median age 52.1 years (range 23-96 years), with symptomatic cholelithiasis, underwent laparoscopic cholecystectomy. On the basis of different selection criteria and surgical techniques adopted, our experience was divided into two periods (93-95 and 96-98). RESULTS: The success rate was 89.4% (371 patients) with a conversion rate of 10.6% (44 patients). Overall complications rate was 2.9% (12 patients): 7 major complications (2 biliary tract injuries, 2 hemorrhages, 1 sub-phrenic abscess, 1 gastric perforation and 1 choleperitoneum) and 3 minor complications (1 biliary leakage and 2 wound infections) with 2 long-term sequela (umbilical site eventration). Median hospital stay was 3.3 days, 2.2 days for uncomplicated cases and 5.6 in those converted or complicated. Comparison between the two groups showed a conversion rate of 10.6 vs 10.4% (23 vs 21 patients), with a complication rate of 4.2% vs 2.2%. CONCLUSIONS: Laparoscopic cholecystectomy can be considered a safe and effective procedure for the treatment of simple or complicated cholelithiasis. French surgical technique seems to be easier in the management of acute cholecystitis or lithiasis occurring after acute pancreatitis. Specific training in laparoscopy surgery is mandatory to avoid major complications.

[The topical therapy of ulcerative colitis. A multicenter study with beclomethasone dipropionate foam]. / Terapia topica della colite ulcerosa. Studio multicentrico con beclometasone dipropionato schiuma.

BACKGROUND AND AIMS: The use of steroids was recently extended to the various forms of ulcerative rectocolitis by the introduction of topical formulations, above all steroids with an hepatic "first pass" devoid of systemic interference. The aim of this study was to evaluate the efficacy and tolerability of Beclomethasone dipropionate (BDP) in a rectal foam formulation, in the treatment of patients suffering from ulcerative colitis. METHODS: The experimental protocol took the form of a 28-day open prospective trial using BDP rectal foam in patients suffering from ulcerative colitis. Endoscopic, histological, clinical and tolerability parameters were evaluated. The centres taking part in the trial collected data for 60 cases out of a total of 80 patients enrolled in the study, of both sexes and aged between 20 and 81 years old, suffering from proctosigmoiditis (46.7%) and ulcerative rectocolitis (53.3%). RESULTS: Endoscopic parameters showed an improvement after 28 days of treatment in 74.5% of patients; a clinical improvement was achieved in 65.2% of cases. In percentage terms of the mean value of all the improved parameters, histological parameters were altered in 56.9% of patients. With regard to tolerability 82% of patients judged the treatment to be good/excellent. CONCLUSIONS: In conclusion, in line with recent reports regarding other pharmaceutical forms of BDP, including the use of rectal foam, these data confirm the efficacy and tolerability of this molecule and emphasise the validity of its use in the treatment of ulcerative colitis and proctosigmoiditis.

[Malignant anorectal melanoma: description of a clinical case and review of the literature]. / Mélanome malin ano-rectal: description d'un cas clinique et revue de la littérature.

Malignant ano-rectal melanoma is a rare pathology without characteristic symptoms. It is more frequent in females than in males (ratio 2:1) and represents 3-15% of anal canal tumours. A case of a woman who recently came to us complaining of painful defecation, tenesmus and rectal bleeding induced us to reconsider the diagnostic and therapeutic implications in ano-rectal melanoma. The low incidence of cases reported and the negative 5-year prognosis are due to late, often incidental, diagnosis during clinical observation for hemorrhoids, rectal polyps or rhagades, together with the aspecificity of the tumour symptoms. We hope our case report emphasizes the importance of conducting early diagnosis in patients at risk of ano-rectal melanoma.

Which kind of surgery in elderly people for colorectal cancer?

Colo-rectal cancers are of high incidence in elderly patients. Different clinical features and the peculiar behavior of the tumor may influence surgical results and should be considered in the decision making, when the surgeon has to decide whether to perform radical gut resection or less straining palliative procedures. In a retrospective study, 102 large bowel cancer patients are analyzed submitted to surgery in the period 1989-1994. Patients were divided in two age classes: Group A: above 70 years of age, 45 cases (44.2%); Group B: under 70 years of age, 57 cases (55.8%). Emergency surgery procedures were necessary in 35 patients (34.4%), 20 cases (57%) in Group A and 15 cases (43%) in Group B. Radical resections could be performed in 25 (37%) old patients, 67% of the cases underwent a curative resection. Perioperative mortality and surgical complication rates were significantly higher in Group A than in Group B. The technical and biological difficulties in performing radical curative resections, the high complication rates and the occurrence of negative results of treatments provide a reason for careful evaluation of the risk/benefit ratio in older patients, where less straining palliative therapies may sometimes offer similar results.

[Surgery in neoplasms of the low rectum. Analysis of the Knight-Griffen technique]. / La chirurgia delle neoplasie del retto inferiore. Analisi della tecnica di Knight-Griffen.

The major advantage offered by the "double stapling technique" in the treatment of low rectum cancers is sphincter preservation while respecting oncological criteria of radicality. The authors report their experience in surgical treatment of rectal neoplasms, considering a 24 patient group observed between 1989 and 1991, when new staplers were available in Italy. They also present primary results obtained with modified Knight-Griffen technique evaluating a series of 10 patients with rectal cancers placed between 5 and 10 cm from the anal verge. The authors describe surgical procedures and, analyse the complication rate, report a 10% anastomotic leak with no clinical stenosis and 20% relapses. Showing a 2-year follow-up data, a 61.1% surviving actually free of disease in the all 24-patient group is referred. The authors conclude that double stapling technique, while safe and effective, should be always performed accordingly to oncological radicality, reminding that the aim of surgery is the treatment of cancer and sphincter saving should be considered secondary.