A Hospital Protocol for Decision Making in Emergency Admission for Acute Diverticulitis: Initial Results from Small Cohort Series.

Background and objectives: We present initial results from a small cohort series for a hospital protocol related to the emergency hospitalization decision-making process for acute diverticulitis. We performed a retrospective analysis of 53 patients with acute diverticulitis admitted to the Department of Emergency and Trauma Surgery of the "Azienda Ospedaliero Universiaria-Ospedali Riuniti" in Ancona and to the Department of General and Emergency Surgery of the "Azienda Ospedaliera-Universitaria" in Perugia. Materials and Methods: All patients were evaluated according to hemodynamic status: stable or unstable. Secondly, it was distinguished whether patients were suffering from complicated or uncomplicated forms of diverticulitis. Finally, each patient was assigned to a risk class. In this way, we established a therapeutic/diagnostic process for each group of patients. Results: Non-operative treatment (NonOP) was performed in 16 patients, and it was successful in 69% of cases. This protocol primarily considers the patient's clinical condition and the severity of the disease. It is based on a multidisciplinary approach, in order to implement the most suitable treatment for each patient. In stable patients with uncomplicated diverticulitis or complicated Hinchey grade 1 or 2 diverticulitis, the management is conservative. In all grade 3 and grade 4 forms, patients should undergo urgent surgery. Conclusions: This protocol, which is based on both anatomical damage and the severity of clinical conditions, aims to standardize the choice of the best diagnostic and therapeutic strategy for the patient in order to reduce mortality and morbidity related to this pathology.

Efficacy of tigecycline and rifampin alone and in combination against Enterococcus faecalis biofilm infection in a rat model of ureteral stent.

BACKGROUND: We investigated the efficacy of tigecycline and rifampin alone or combined in preventing ureteral stent infection due to Enterococcus faecalis. MATERIALS AND METHODS: The activities of the two antibiotics were previously studied in vitro in absence or in presence of biofilm. For in vivo research, the study included a control group without bacterial challenge to evaluate the sterility of surgical procedure, a challenged control group that did not receive any antibiotic prophylaxis and, for each bacterial strain, three challenged groups that received: (1) 2 mg/kg intraperitoneal tigecycline, immediately after stent implantation; (2) rifampin-coated ureteral stents where 0.2 cm(2) sterile ureteral stents were incubated in 10 mg/L rifampin solution for 30 min immediately before implantation; and (3) intraperitoneal tigecycline plus rifampin-coated ureteral stent at the above concentrations. Ureteral stents were explanted at d 5 following implantation and biofilm bacteria enumerated. RESULTS: The in vitro studies showed that the biofilm was strongly affected by the presence of rifampin and, in its presence, tigecycline had MICs and MBCs lower than those obtained in the absence of rifampin. Intraperitoneal tigecycline exerted stronger effect than rifampin on bacterial numbers. The combination rifampin plus tigecycline showed efficacies higher than that of each single compound. CONCLUSION: These results highlight the potential usefulness of tigecycline in preventing enterococcal ureteral stent infections and the role of rifampin as an interesting antibiotic enhancer.

Effect of the combination of clarithromycin and amikacin on Pseudomonas aeruginosa biofilm in an animal model of ureteral stent infection.

OBJECTIVES: An experimental study was performed to evaluate both in vitro and in vivo the efficacy of clarithromycin coating combined with systemic amikacin in preventing ureteral stent biofilm infection due to Pseudomonas aeruginosa. METHODS: The activities of the two antibiotics were studied in vitro in the absence or in the presence of biofilm. For the in vivo study we evaluated a control group without bacterial challenge to evaluate the sterility of the surgical procedure, a challenged control group that did not receive any antibiotic prophylaxis and three challenged groups that received (i) 15 mg/kg intraperitoneal amikacin immediately after stent implantation, (ii) clarithromycin-coated ureteral stents where 0.2 cm² sterile ureteral stents were incubated in 10 mg/L clarithromycin solution for 30 min immediately before implantation, and (iii) intraperitoneal amikacin plus a clarithromycin-coated ureteral stent at the above concentrations. RESULTS: The in vitro studies showed that the biofilm was strongly affected by the presence of clarithromycin and, in its presence, amikacin had MICs and MBCs lower than those obtained in the absence of clarithromycin. For the singly treated groups, intraperitoneal amikacin showed the strongest effect on bacterial numbers. A clarithromycin coating combined with systemic amikacin showed an efficacy that was higher than that of each single compound. CONCLUSIONS: The prevention of ureteral stent Pseudomonas biofilm infection was enhanced by impregnation of the stent with clarithromycin combined with systemic amikacin.

Lipopeptide Laur-CKK-NH2 dimer preserves daptomycin susceptibility and enhances its activity against Enterococcus faecalis.

OBJECTIVES: An experimental study was performed to evaluate both in vitro and in vivo the kind of interaction between the Laur-CKK-NH2 dimer and daptomycin using two Enterococcus faecalis strains with different patterns of susceptibilities. METHODS: We evaluated whether selection for daptomycin-resistant E. faecalis could be prevented in vitro by combining daptomycin with the Laur-CKK-NH2 dimer. The strains were serially exposed in broth to 2-fold stepwise increasing concentrations of daptomycin alone or in combination with a fixed concentration (0.25×MIC) of the Laur-CKK-NH2 dimer. We also performed an in vitro synergy study. For in vivo studies, a mouse model of enterococcal sepsis was used. RESULTS: In vitro experiments: exposure to daptomycin alone gradually selected for enterococci with increased MICs; and the Laur-CKK-NH2 dimer showed a positive interaction with daptomycin and was able to prevent the resistance. In vivo experiments: the main outcome measures were lethality and quantitative blood cultures; and the Laur-CKK-NH2 dimer combined with daptomycin exhibited the highest efficacy for all main outcome measurements. CONCLUSIONS: These results highlight the potential usefulness of combining daptomycin with the Laur-CKK-NH2 dimer. The combination provides a future therapeutic alternative for the treatment of enterococcal severe infections.

Protective effect of citropin 1.1 and tazobactam-piperacillin against oxidative damage and lethality in mice models of gram-negative sepsis.

BACKGROUND: Gram-negative sepsis ranks as the leading cause of death in intensive care units, and its incidence is increasing steadily and mortality rates has not changed much over recent decades. MATERIALS AND METHODS: We investigated the efficacy of the amphibian peptide, citropin 1.1 alone and in combination with tazobactam-piperacillin (TZP) in two experimental mice models of gram-negative sepsis. Animals were given an intraperitoneal injection of (1) 1 mg Escherichia coli 0111:B4 LPS, and (2) 2×10(10) CFU of E. coli ATCC 25922. For each model, all animals were randomized to receive intraperitoneally isotonic sodium chloride solution, 1 mg/Kg citropin 1.1 and 120 mg/Kg of TZP, and finally 1 mg/Kg citropin 1.1 plus 60 mg/Kg of TZP. Lethality, bacterial growth in blood and peritoneum, and oxidative stress indices in plasma were evaluated. RESULTS: All compounds reduced the lethality compared with controls. Treatment with citropin 1.1 resulted in significant decrease in plasma endotoxin and cytokine levels, while TZP exerted opposed effect. The combination between citropin 1.1 and TZP proved to be the most effective treatment in reducing all variables measured. CONCLUSION: Due to its multifunctional properties, citropin 1.1 may become an important future consideration to treat conditions in which oxidative organ failure may be present.

Treatment of rectal adenomas by transanal endoscopic microsurgery: 15 years' experience.

BACKGROUND: The authors present their experience with rectal adenomas managed by transanal endoscopic microsurgery (TEM). The goals of this study were to examine our institution's experience by evaluating surgical morbidity, mortality, and local recurrence rate. METHODS: This retrospective study investigated 402 patients who underwent TEM a for preoperative diagnosis of adenoma from January 1993 to October 2008. The mean age was 65 years (range = 22-92 years). All patients were regularly followed up to determine treatment efficacy in terms of local recurrence rate. RESULTS: No 30-day perioperative mortality occurred. No conversion to laparoscopic or open procedures was reported. Minor complications occurred in 28 (7%) patients, whereas major complications were found only in 2 (0.5%) patients. Definitive histology confirmed adenomas in 366 cases (91%). At a mean follow-up of 84 months (range = 1-190 months), 16 (4%) adenomas recurred and were successfully retreated by TEM [14 cases (87.5%)] and by conventional surgery [2 patients (12.5%)]. No further recurrences were observed at subsequent follow-up. CONCLUSION: The findings warrant the conclusion that TEM is a safe, effective treatment for rectal adenomas where endoscopic removal is not applicable and has low morbidity and no mortality.

[Laparoscopic surgery of rectal cancer: state of art and long-term results]. / Chirurgia laparoscopica del cancro del retto. Stato dell'arte e risultati a lungo termine.

BACKGROUND: From the first laparoscopic colectomy that we performed 18 years ago, several studies showed equivalent oncologic results of this technique compared to open surgery Despite this evidence traditional surgeons remain skeptical in the use of this technique, although it may favor an early return of bowel function and therefore a shorter hospitalization, as reported in recent comparative studies. Many colorectal surgeons, who have appreciated the advantages of laparoscopic colectomy, extended this approach also in rectal cancer, finding a better view in the pelvis during dissection. METHOD: From 1992 to july 2009 we performed more than 400 laparoscopic resection and amputation for rectal cancer. One hundreds eighteen patients (TNM stage I-III) with a 36 month minimum follow-up were enrolled in this analysis. Converted patients to open surgery and patients staged as iT1N0 are not present in this series because we treat with local excision by TEM. RESULTS: Mean operative time was 160 minutes (90-265). Mortality was 1% in 186 patients and conversion rate was 1.5%. Major complications occurred in 10.7%, including anastomotic leakage in 14 patients (7.5%) and mean hospital stay was 7.7 days. With a mean follow up of 96.8 (36-175) months in the stage I-III, the local recurrence rate was 12.5%. Systematic recurrence occurred in 13.1%. CONCLUSION: Laparoscopic resection in rectal cancer would allow the use of the same Heald's technique, respecting the Heald's principle of meticulous dissection during total mesorectal excision, furthermore we are waiting 5 years data from randomized trials (COLOR II and CLASICC).

Damage control surgery for perforated diverticulitis with diffuse peritonitis: saves lives and reduces ostomy.

Introduction: Over the last decade, damage control surgery (DCS) has been emerging as a feasible alternative for the management of patients with abdominal infection and sepsis. So far, there is no consensus about the role of DCS for acute perforated diverticulitis. In this study, we present the outcome of a multi-institutional series of patients presenting with Hinchey's grade III and IV diverticulitis managed by DCS. Methods: All the participating centers were tertiary referral hospitals. A total of 34 patients with perforated diverticulitis treated with DCS during the period 2011-2017 were included in the study. During the first laparotomy, a limited resection of the diseased segment was performed followed by lavage and use of negative pressure wound therapy (NPWT). After 24/48 h of resuscitation, patients returned to the operating room for a second look. Mortality, morbidity, and restoration of bowel continuity were the primary outcomes of the study. Results: There were 15 males (44%) and 19 females (56%) with a mean age of 66.9 years (SD ± 12.7). Mean BMI was 28.42 kg/m2 (SD ± 3.33). Thirteen cases (38%) were Wasvary's modified Hinchey's stage III, and 21 cases (62%) Hinchey's stage IV. Mean Mannheim Peritonitis Index (MPI) was 25.12 (SD ± 6.28). In 22 patients (65%), ASA score was ≥ grade III. Twenty-four patients (71%) had restoration of bowel continuity, while 10 (29%) patients had an end colostomy (Hartmann's procedure). Three of these patients received a temporary loop ileostomy. One patient had an anastomotic leak. Mortality rate was 12%. Mean length of hospital stay was 21.9 days. At multivariate analysis, male gender (p = 0.010) and MPI (p = 0.034) correlated with a high percentage of Hartmann's procedures. Conclusion: DCS is a feasible procedure for patients with generalized peritonitis secondary to perforated diverticulitis, and it appears to be related to a higher rate of bowel reconstruction. Due to the open abdomen, stay in ICU with prolonged mechanical ventilation is required, but these aggressive measures may be needed by most patients undergoing surgery for perforated diverticulitis, whatever the procedure is done.

The role of grade of injury in non-operative management of blunt hepatic and splenic trauma: Case series from a multicenter experience.

This retrospective study shows the results of a 2 years application of a clinical pathway concerning the indications to NOM based on the patient's hemodynamic answer instead of on the injury grade of the lesions.We conducted a retrospective study applied on a patient's cohort, admitted in "Azienda Ospedaliero-Universitaria Ospedali Riuniti of Ancona" and in the Digestive and Emergency Surgery Department of the Santa Maria of Terni hospital between September 2015 and December 2017, all affected by blunt abdominal trauma, involving liver, spleen or both of them managed conservatively. Patients were divided into 3 main groups according to their hemodynamic response to a fluid administration: stable (group A), transient responder (group B) and unstable (group C). Management of patients was performed according to specific institutional pathway, and only patients from category A and B were treated conservatively regardless of the injury grade of lesions.From October 2015 to December 2017, a total amount of 111 trauma patients were treated with NOM. Each patient underwent CT scan at his admission. No contrast pooling was found in 50 pts. (45.04%). Contrast pooling was found in 61 patients (54.95%). The NOM overall outcome resulted in success in 107 patients (96.4%). NOM was successful in 100% of cases of liver trauma patients and was successful in 94.7% of splenic trauma patients (72/76). NOM failure occurred in 4 patients (5.3%) treated for spleen injuries. All these patients received splenectomy: in 1 case to treat pseudoaneurysm, (AAST, American Association for the Surgery of Trauma, grade of injury II), in 2 cases because of re-bleeding (AAST grade of injury IV) and in the remaining case was necessary to stop monitoring spleen because the patient should undergo to orthopedic procedure to treat pelvis fracture (AAST grade of injury II).Non-operative management for blunt hepatic and splenic lesions in stable or stabilizable patients seems to be the choice of treatment regardless of the grade of lesions according to the AAST Organ Injury Scale.

Electrothermal bipolar vessel sealing device vs. ultrasonic coagulating shears in laparoscopic colectomies: a comparative study.

BACKGROUND: Many devices are available for vascular control during laparoscopic colorectal procedures. Ultrasonic coagulating shears (UCS), vascular staplers, titanium or plastic clips, and electrothermal bipolar vessel sealing (EBVS) are currently used according to the surgeon's preference. This study aimed to compare EBVS Ligasure with UCS. METHODS: We report the outcome of 200 consecutive unselected patients who underwent laparoscopic colorectal resections of which 100 were performed with EBVS Ligasure (from September 2004 to December 2005, group 1) and 100 with UCS harmonic scalpel (from December 2002 to June 2004, group 2). Only the following three types of operation were performed: right colectomy (RC), left colectomy (LC), and low anterior resections (LAR). Emergency procedures have been excluded. The same attending surgical teams performed or supervised all procedures. Operating time, blood loss, complications, and postoperative hospital stay were investigated. RESULTS: Age, gender, previous surgical abdominal procedures, and ASA risk were similar between the two groups, as well as was the percentage of malignant cases (74% vs. 71%, respectively). There were 32 vs. 37 RC, 50 vs. 47 LC, and 18 vs. 16 LAR in groups 1 and 2, respectively. There was no mortality in either group. A conversion to open surgery and two major complications occurred in group 2. There were no statistically significant differences in mean operating time (111 vs. 133, 140 vs. 176, and 153 vs. 201 min) and in the mean postoperative hospital stay (5.2 vs. 6.1, 6.5 vs. 7.1, and 6.8 vs 7.3 days) for RC, LC, and LAR between group 1 and 2, respectively. We do report interesting data about statistically significant differences in the blood loss: 115 vs. 370, 150 vs. 455, and 185 vs. 495 ml for RC (p < 0.001), LC (p < 0.001), and LAR (p = 0.002) between group 1 and group 2, respectively. CONCLUSIONS: In our laparoscopic colorectal experience, EBVS Ligasure has proven safe and effective in vessel sealing. Patients in whom this device was used had less blood loss and slight advantages in operating time and postoperative hospital stay.

Blunt hepatic and splenic trauma. A single Center experience using a multidisciplinary protocol.

AIM: The aim of this retrospective study was to describe more than 10 years experience of a single Trauma Center about non operative management of abdominal organ injuries in hemodynamically stable patients MATERIAL OF STUDY: Between January 2001 and December 2014 ,732 consecutive patients were admitted with blunt abdominal trauma, involving liver and/or spleen and/or kidney, at the Bufalini Cesena Hospital .Management of patients included a specific institutional developed protocol :hemodynamic stability was evaluated in shock room according to the patients response to fluid challenge and the patients were classified into three categories A,B,and C. RESULTS: Form 732 Trauma, 356(48.6%) of patients were submitted to a surgical procedure, all the other patient 376(51.4%) underwent an non operative management .Overall mortality was 9.8% (72), mortality in the surgery group was 15.4% eheras in the non operative group was 4.5%; the relative risk of mortality, measured by the odds ratio waith a 95% confidence interval, was 3.417(2.023-5.772) for rhe surgery group; patient over 40 years old has a statistically significant higher mortality. DISCUSSION: In our series the overall mortality rate of non operative management group was 4.5%, instead in unstable patients, the surgery group, the mortality was 15.3%; the overall mortality mortality rate after the application of our protocol is 9.8%, Although surgery continues to be the standard for hemodically unstable patients with blunt hepatic and splenic trauma. In our experience AAST Organ Injury Scale was useless for the therapeutic decision making process after the CT scan if a source of bleeding was detected and immediate angiography was performed in order to control and solve it. CONCLUSIONS: In our experience the AAST Organ Injury Scale was useless for the therapeutic decision making process, The results suggest that the only criteria of choice for therapeutici strategy was the hemodynamic stability, Nonoperative managem,ent can be applied only following strict institutional criteria KEY WORDS: Hemodynmic stability, Nonoperative management, Trauma.