The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis.

OBJECTIVES: To assess the safety and efficacy of antibiotics treatment for suspected acute uncomplicated appendicitis and to monitor the long term follow-up of non-operated patients. BACKGROUND: Right lower quadrant abdominal pain is a common cause of emergency department admission. The natural history of acute appendicitis nonoperatively treated with antibiotics remains unclear. METHODS: In 2010, a total of 159 patients [mean AIR (Appendicitis Inflammatory Response) score = 4.9 and mean Alvarado score = 5.2] with suspected appendicitis were enrolled and underwent nonoperative management (NOM) with amoxicillin/clavulanate. The follow-up period was 2 years. RESULTS: Short-term (7 days) NOM failure rate was 11.9%. All patients with initial failures were operated within 7 days. At 15 days, no recurrences were recorded. After 2 years, the overall recurrence rate was 13.8% (22/159); 14 of 22 patients were successfully treated with further cycle of amoxicillin/clavulanate. No major side effects occurred. Abdominal pain assessed by the Numeric Rating Scale and the visual analog scale; median Numeric Rating Scale score was 3 at 5 days and 2 after 7 days. Mean length of stay of nonoperatively managed patients was 0.4 days, and mean sick leave period was 5.8 days. Long-term efficacy of NOM treatment was 83% (118 patients recurrence free and 14 patients with recurrence nonoperatively managed). None of the single factors forming the Alvarado or AIR score were independent predictors of failure of NOM or long-term recurrence. Alvarado and AIR scores were the only independent predictive factors of NOM failure after multivariate analysis, but both did not correlate with recurrences. Overall costs of NOM and antibiotics were &OV0556;316.20 per patient. CONCLUSIONS: Antibiotics for suspected acute appendicitis are safe and effective and may avoid unnecessary appendectomy, reducing operation rate, surgical risks, and overall costs. After 2 years of follow-up, recurrences of nonoperatively treated right lower quadrant abdominal pain are less than 14% and may be safely and effectively treated with further antibiotics.

Changes in the outcomes of severe trauma patients from 15-year experience in a Western European trauma ICU of Emilia Romagna region (1996-2010). A population cross-sectional survey study.

BACKGROUND: Our experience in trauma center management increased over time and improved with development of better logistics, optimization of structural and technical resources. In addition recent Government policy in safety regulations for road traffic accident (RTA) prevention, such compulsory helmet use (2000) and seatbelt restraint (2003) were issued with aim of decreasing mortality rate for trauma. INTRODUCTION: The evaluation of their influence on mortality during the last 15 years can lead to further improvements. METHODS: In our level I trauma center, 60,247 trauma admissions have been recorded between 1996 and 2010, with 2183 deaths (overall mortality 3.6 %). A total of 2,935 trauma patients with ISS >16 have been admitted to Trauma ICU and recorded in a prospectively collected database (1996-2010). Blunt trauma occurred in 97.1 % of the cases, whilst only 2.5 % were penetrating. A retrospective review of the outcomes was carried out, including mortality, cause of death, morbidity and length of stay (LOS) in the intensive care unit (ICU), with stratification of the outcome changes through the years. Age, sex, mechanism, glasgow coma scale (GCS), systolic blood pressure (SBP), respiratory rate (RR), revised trauma score (RTS), injury severity score (ISS), pH, base excess (BE), as well as therapeutic interventions (i.e., angioembolization and number of blood units transfused in the first 24 h), were included in univariate and multivariate analyses by logistic regression of mortality predictive value. RESULTS: Overall mortality through the whole period was 17.2 %, and major respiratory morbidity in the ICU was 23.3 %. A significant increase of trauma admissions has been observed (before and after 2001, p < 0.01). Mean GCS (10.2) increased during the period (test trend p < 0.05). Mean age, ISS (24.83) and mechanism did not change significantly, whereas mortality rate decreased showing two marked drops, from 25.8 % in 1996, to 18.3 % in 2000 and again down to 10.3 % in 2004 (test trend p < 0.01). Traumatic brain injury (TBI) accounted for 58.4 % of the causes of death; hemorrhagic shock was the death cause in 28.4 % and multiple organ failure (MOF)/sepsis in 13.2 % of the patients. However, the distribution of causes of death changed during the period showing a reduction of TBI-related and increase of MOF/sepsis (CTR test trend p < 0.05). Significant predictors of mortality in the whole group were year of admission (p < 0.05), age, hemorrhagic shock and SBP at admission, ISS and GCS, pH and BE (all p < 0.01). In the subgroup of patients that underwent emergency surgery, the same factors confirmed their prognostic value and remained significant as well as the adjunctive parameter of total amount of blood units transfused (p < 0.05). Surgical time (mean 71 min) showed a significant trend towards reduction but did not show significant association with mortality (p = 0.06). CONCLUSION: Mortality of severe trauma decreased significantly during the last 15 years as well as mean GCS improved whereas mean ISS remained stable. The new safety regulations positively influenced incidence and severity of TBI and seemed to improve the outcomes. ISS seems to be a better predictor of outcome than RTS.

Management and outcome of 308 cases of liver trauma in Bologna Trauma Center in 10 years.

INTRODUCTION: Management of Liver Trauma may vary widely from NOM +/- angioembolization to Damage Control Surgery. Multidisciplinary management is essential for achieving better outcomes. MATERIAL AND METHODS: During 2000-2009 period 308 patients with liver injury were admitted to level 1 trauma center and recorded in Trauma Registry. Collected data are demographics, AAST grade, initial treatment (operative or non-operative treatment) and outcome (failure of NOM), death. All patients were initially assessed according to ATLS guidelines. In case of haemodynamic instability and FAST evidence of intra-abdominal free fluid, the patients underwent immediate laparotomy. Hemodynamically stable patients, underwent CT scan and were admitted in ICU for NOM. RESULTS: Two hundred fourteen patients (69.5%) were initially managed with NOM. In 185 patients this was successful. Within the other 29 patients, failure of NOM was due to liver-related causes in 12 patients and non-liver-related causes in 17 Greater the grade of liver injury, fewer patients could be enrolled for NOM (85.8% in I-II and 83.3% in III against 39.8% in IV-V). Of those initially treated non-operatively, the likelihood of failure was greater in more severely injured patients (24.4% liver-related failure rate in IV-V against the 1.3% and 1.0% in I-II and III respectively). One hundred twenty-three patients (40% of the whole population study--308 patients) underwent laparotomy: 94 immediately after admission, because no eligible for NOM; 29 after NOM failure . In the 81 patients in which liver bleeding was still going on at laparotomy, hemostasis was attempted in two different ways: in the patients affected by hypothermia, coagulopathy and acidosis, perihepatic packing was the treatment of choice. In the other cases a "direct repair" technique was preferred. "Early mortality" which was expected to be worse in patients with such metabolic derangements, was surprisingly the same of the other group. This proves efficacy of the packing technique in interrupting the "vicious cicle" of hypothermia, coagulopathy and acidosis, therefore avoiding death ("early death" in particular) from uncontrollable bleeding. CONCLUSION: NOM +/- angioembolization is safe and effective in any grade of liver injury provided hemodynamic stability. DCS is Gold Standard for hemodynamically unstable patients.

[The Elhers-Danlos syndrome: an insidious pathology. Presentation of a familiary group]. / La sindrome di Elhers-Danlos: una patologia insidiosa. Presentazione di un gruppo familiare.

INTRODUCTION: Elhers-Danlos Syndrome (EDS) is an hereditary disease of the connective tissue, which may have clinical appearances varying in its severity from subclinical asymptomatic forms up to dramatic uncontrollable haemorrhage. MATERIALS AND METHODS: We have observed three siblings who were carriers of vascular type EDS. They were otherwise healthy at the time of the disease presentation and have become symptomatic since then, developing severe and uncontrollable haemorrhage. RESULTS: We have reported the clinical presentation of this syndrome, the clinical and laboratory characteristics, the treatment and the outcome. CONCLUSIONS: Although the severity of this disease, Elhers-Danlos Syndrome becomes symptomatic lately and suddenly in its course, often during emergency surgery for haemorrhagic shock. Several issues are raised such as the possibility for early diagnosis of this disease, the psychological features of a genetic counseling, the need for the patients to have adequate lifestyle and last but not least the risk of genetic transmission of the disease.

Ectopic thyroid tissue in the adrenal gland: report of a case.

Foci of ectopic thyroid tissue are uncommon. Most sites of thyroid ectopia are confined to the neck region. The presence of ectopic thyroid tissue outside the migration pathway of the primitive thyroid in other locations is exceptional. Given that any disease of the thyroid gland may also affect ectopic thyroid tissue, pathologists has to recognize benign or malignant conditions that may develop in the ectopic focus. We present the case of a 32-year-old woman with ectopic thyroid parenchyma in the adrenal gland. Clinically, postoperative thyroid ultrasound echography and computed tomography scans did not reveal any thyroid tumor. The ectopic tissue was a cyst bordered by mature follicular thyroid structures and was histologically benign, without the molecular alterations associated with malignant tumors of follicular cell derivation (BRAFV600E, N-RAS, H-RAS, K-RAS). Review of the literature reveals that adrenal ectopic thyroid tissue is nearly always cystic and has distinctive pathologic features.

Dyspnea and large bowel obstruction: a misleading Chilaiditi syndrome.

Chilaiditi sign is named after the Greek radiologist Demetrius Chilaiditi who first described it when he was working in Vienna In (1910), and it is an incidental radiographic finding. This sign can be more frequently mistaken for pneumoperitoneum which is usually an indication of bowel perforation and can lead to needless surgical intervention. There are several case report reported in literature that describe the association between colonic volvulus and Chilaiditi syndrome that underline the frequent association between these anatomical condition instead no previous report described the association between Chilaiditi syndrome and large bowel obstruction secondary to a malignant sigmoid stenosis in a man presenting with symptoms and signs of upper respiratory distress combined with subacute bowel obstruction.

Prognosis and treatment of pancreaticoduodenal traumatic injuries: which factors are predictors of outcome?

BACKGROUND/PURPOSE: Abdominal trauma rarely causes injuries involving the duodenum and pancreas. Associated injuries occur in 46% of all pancreatic injuries. The morbidity and mortality of pancreaticoduodenal injuries remain high. METHODS: The present study is a retrospective review of our experience from 1989 to 2008 in the surgical treatment of traumatic pancreaticoduodenal injuries. Mortality, morbidity, prognostic factors, and the value of surgical techniques were analyzed. RESULTS: In our level I Trauma Center, between 1989 and 2008, 55 patients had a pancreaticoduodenal injury. In 68.5% of cases pancreatic injuries were found, 20.4% had duodenal injury, and 11.1% suffered combined pancreaticoduodenal injuries; 85.3% of the patients had blunt abdominal trauma, while 14.9% had penetrating injuries. We treated 78.1% of the patients with external drainage and/or simple suture; distal pancreatectomy was performed in 9% of cases and duodenal resection with anastomosis (3.7%) and diversion procedures (3.7%) were performed in an equal number of patients. Age, American Association for the Surgery of Trauma (AAST) grade, organ involved, hemodynamic status, intraoperative cardiac arrest, and operative time remained strongly predictive of mortality on multivariate analysis. The AAST grade represented, on multivariate analysis, the only independent prognostic factor predictive of overall morbidity. In the past decade we have used feeding jejunostomy more frequently, with a reduction of mortality and operating time, due also to a better approach from a dedicated trauma team. CONCLUSIONS: Optimal management and better outcome of pancreaticoduodenal injuries seem to be associated with shorter operative time, and with simple and fast damage control surgery (DCS), in contrast to definitive surgical procedures.

The NOTA study: non-operative treatment for acute appendicitis: prospective study on the efficacy and safety of antibiotic treatment (amoxicillin and clavulanic acid) in patients with right sided lower abdominal pain.

BACKGROUND: Case control studies that randomly assign patients with diagnosis of acute appendicitis to either surgical or non-surgical treatment yield a relapse rate of approximately 14% at one year. It would be useful to know the relapse rate of patients who have, instead, been selected for a given treatment based on a thorough clinical evaluation, including physical examination and laboratory results (Alvarado Score) as well as radiological exams if needed or deemed helpful. If this clinical evaluation is useful, the investigators would expect patient selection to be better than chance, and relapse rate to be lower than 14%. Once the investigators have established the utility of this evaluation, the investigators can begin to identify those components that have predictive value (such as blood analysis, or US/CT findings). This is the first step toward developing an accurate diagnostic-therapeutic algorithm which will avoid risks and costs of needless surgery. METHODS/DESIGN: This will be a single-cohort prospective observational study. It will not interfere with the usual pathway, consisting of clinical examination in the Emergency Department (ED) and execution of the following exams at the physician's discretion: full blood count with differential, C reactive protein, abdominal ultrasound, abdominal CT. Patients admitted to an ED with lower abdominal pain and suspicion of acute appendicitis and not needing immediate surgery, are requested by informed consent to undergo observation and non operative treatment with antibiotic therapy (Amoxicillin and Clavulanic Acid). The patients by protocol should not have received any previous antibiotic treatment during the same clinical episode. Patients not undergoing surgery will be physically examined 5 days later. Further follow-up will be conducted at 7, 15 days, 6 months and 12 months. The study will conform to clinical practice guidelines and will follow the recommendations of the Declaration of Helsinki. The protocol was approved on November 2009 by Maggiore Hospital Ethical Review Board (ID CE09079). Trial Registration ClinicalTrials.gov identifier: NCT01096927.

Bariatric Revisionary Surgery for Failed or Complicated Vertical Banded Gastroplasty (VBG): Comparison of VBG Reoperation (re-VBG) versus Roux-en-Y Gastric Bypass-on-VBG (RYGB-on-VBG).

Background. Revision of failed bariatric procedures is a significant challenge for bariatric surgeons, because of the increasing number of recurring morbid obesity or complications, especially in patients with a previous Vertical Banded Gastroplasty (VBG). Methods. Since November 1998, 109 patients with failed or complicated VBG were followed in a retrospective study. 49 patients underwent re-VBG and, since 2004, 60 underwent Roux-en-Y Gastric Bypass-on-Vertical Banded Gastroplasty (RYGB-on-VBG). Results. At 3 years follow-up, mean BMI decreased from 37.4 to 31.2 Kg/m(2) in the first group, and from 35.0 to 28.4 Kg/m(2) in the second. Early complications were 7 (14.3%) in the first group and 4 (6.5%) in the second; late complications were 33 (59.1%) and 11 (18.3%), respectively. Conclusion. Although both operations seem to be effective as bariatric revision procedures in terms of BMI, the mid-term outcomes of RYGB-on-VBG demonstrate the lowest rate of complications and better quality of life.