Assessment of tetanus immunity status by tetanus quick stick and anamnesis: a prospective double blind study.

BACKGROUND: In patients with wounds admitted to Emergency Departments (ED) acquiring tetanus vaccination history by interview is very unreliable. Protected patients may receive unnecessary prophylaxis and unprotected nothing. Aim of the study was to evaluate tetanus immunity status comparing the traditional anamnestic method with the Tetanus Quick Stick (TQS), a rapid immunochromatographic test. METHODS: A double-blind prospective study was carried out in the ED of the 1,000 bed teaching hospital Umberto I in Rome. Adult patients (≥18) with wounds attending at the ED were randomly included. Tetanus immunity status was evaluated by healthcare workers (HCWs) comparing the TQS test with the anamnesis. TQS test was performed by a trained HCW and afterwards the anamnesis about tetanus immunity status was collected by another HCW unaware of the TQS result. Also cost analysis was carried out. RESULTS: Overall 400 patients (242 males and 158 females) were included, mean age was 46.7 ± 20.2 years (median 44 range 18 - 109), 304 (76.0%) were italians and 96 foreigners (24.0%). Overall, 209 (52.2%) resulted TQS +, and protective immunity level was associated to lower mean age (40.1 ± 16.8 vs 53.8 ± 21,1; p<0,01). Using the anamnestic method 336 (84.0%) patients resulted "unprotected", 52 (13.0%) "partially unprotected" and 12 (3.0%) "completely protected". TQS test results showed that 154 (45.8%) out of 336 "unprotected" and 45 (86.5%) out of 52 "partially unprotected" actually had a protective antibody level. Finally two (16.7%) out of 12 "completely protected" group presented a non protective antibody level. Following only the anamnestic method 201 (50.0%) patients would have received some inappropriate treatment. Adopting TQS test in all patients would also be cost-effective saving € 1.95/patient. As tetanus immunity is inversely related to age, for <51 years old patients unnecessary treatment would have been avoided in 57.1% of patients, with a mean reduction per patient of € 7.50/patient with the TQS vs. € 12.69/patient without. CONCLUSIONS: The study showed that tetanus protective immunity prevalence among adult patients attending our ED is about 50% and is mainly influenced by class age. TQS use allowed to reduce drastically inappropriate tetanus vaccine and immunoglobulins booster treatment. Also TQS use reduced costs.

Laparoscopic management of left paraduodenal hernia. Case report and review of literature.

We report a rare case of left paraduodenal hernia in patient with symptoms of abdominal subobstruction treated successful with laparoscopic management in urgent situation that have reduced the length of stay and postoperative pain. Internal hernia is only 1% of the causes of abdominal obstruction and the left paraduodenal hernia about 50% of them; it is a congenital defect that derive from malrotation and abnormal mesenteric adhesion. The modern imaging techniques help for the correct diagnosis despite difficult identification of the pathology for the various clinical presentation. The treatment of choice is the surgical intervention; the laparoscopic approach is rarely described in literature but it can reduce the morbidity, postoperative pain and the length of hospital stay.

Octogenarians: an increasing challenge for acute care and colorectal surgeons. An outcomes analysis of emergency colorectal surgery in the elderly.

AIM: Emergency surgery is associated with higher mortality rates, especially in elderly patients presenting with emergent colorectal disease. The aim of this study was to determine the outcomes in elderly patients following emergency colorectal resection, with particular focus on octogenarians who presented a sixfold higher mortality rate with respect to other patients. METHOD: This study examined 355 patients who underwent surgery at an Emergency Department for complications of colorectal disease between January 2007 and December 2009. Morbidity and mortality were analyzed on the basis of patients' characteristics and presentation. Univariate and logistic regression analyses were performed on morbidity and mortality risk factors. RESULTS: Two-hundred and fifteen patients of > 65 years of age were included, 93 of whom were ≥ 80 years of age. The global mortality rate was 16%. In patients ≥ 80 years of age the mortality rate was 30%. The difference in mortality rate between patients < 80 years of age vs patients ≥ 80 years of age was 24%. In resected patients ≥ 80 years of age, American Society of Anesthesiology grade, colonic ischaemia, neurological comorbidity and anastomotic dehiscence were identified as independent risk factors in both univariate and logistic regression analyses. The morbidity rate was approximately 17%, and no significant difference in morbidity was found between the two groups. CONCLUSION: The results of this study show that fitness status and micro vascular impairment impact significantly on mortality in the elderly, particularly in octogenarians. Although the outcomes observed were compatible with the literature, the six fold higher mortality rate observed in the most elderly patients identifies a group for which death prevention is best achieved with aggressive resuscitation and intensive postoperative care, rather than timing of surgery.

Ectopic liver nodules: a rare finding during cholecystectomy.

The ectopic liver (or choristoma) is a rare condition found during autopsy or abdominal exploration for various indications. The authors report two cases of ectopic liver found during laparoscopic cholecystectomy for acute cholestytis. The ectopic liver tissue has been reported to develop in several sites as thoracic cavity, gastrohepatic ligament, adrenal glands, pancreas, esophagus and, above all, gallbladder. The Authors review the literature and report their experience as a contribution to the knowledge of this rare pathological entity.

Abdominal emergency in young women: gynecological or bowel disease? Two case reports.

Abdominal pain is a frequent symptom in Emergency Departments. Often is not so easy make a diagnosis of cause. Particular importance in young women has differential diagnosis with gynecological diseases. Often laboratory exams have not good specificity. US and TC are the imaging techniques most used to make a diagnosis, but both have ours limits. Definitely surgeon's experience is the most important resource for a correct approach to abdominal pain. We present two cases of low abdominal pain in young women due to ovarian teratoma erroneously diagnosed as appendicitis.

Laparoscopic treatment of blunt splenic injuries: initial experience with 11 patients.

BACKGROUND: Nonoperative treatment of splenic injuries is the current standard of care for hemodynamically stable patients. However, uncertainty exists about its efficacy for patients with major polytrauma, a high Injury Severity Score (ISS), a high grade of splenic injury, a low Glasgow Coma Score (GCS), and important hemoperitoneum. In these cases, the videolaparoscopic approach could allow full abdominal cavity investigation, hemoperitoneum evacuation with autotransfusion, and spleen removal or repair. METHODS: This study investigated 11 hemodynamically stable patients with severe polytrauma who underwent emergency laparoscopy. The mean ISS was 29.0 +/- 3.9, and the mean GCS was 12.1 +/- 1.6. A laparoscopic splenectomy was performed for six patients, whereas splenic hemostasis was achieved for five patients, involving one electrocoagulation, one polar resection, and three polyglycolic mesh wrappings. RESULTS: The average length of the operation was 121.4 +/- 41.6 min. There were two complications (18.2%), with one conversion to open surgery (9.1%), and no mortality. CONCLUSIONS: Laparoscopy is a safe, feasible, and effective procedure for evaluation and treatment of hemodynamically stable patients with splenic injuries for whom nonoperative treatment is controversial.

Small bowel intussusception: what is the role of laparoscopy?

Small bowel intussusception in adults is a rare surgical disease which almost always occurs as a complication of either benign or malignant lesion of the bowel that is working as a leading point. In adults, the surgical approach consists of the resection of the bowel involved to ensure the excision of the lesion below. The authors report a case of ileocecal intussusception occurred in a young woman, 35 years old, observed for abdominal pain and signs of small bowel occlusion. She underwent surgical resection of the ileocecal segment with laparoscopic approach. The authors discuss the feasibility of the laparoscopic approach in this rare surgical disease and its benefits in terms of patient's postoperative comfort and outcome.

Gastrointestinal bleeding in emergency setting: two cases of intestinal angiodysplasia and unusual conservative surgical treatment.

The authors report two cases of gastrointestinal bleeding in an emergency setting caused by angiodysplasia of colon and small bowel. They stress the rarity of the lesion and consider the difficulties involved in obtaining a preoperative diagnosis. The optimal management is uncertain and depends on the severity and rate of bleeding. A conservative medical approach is indicated for many patients, while surgery constitutes definitive treatment in case of massive hemorrhage or recurrent bleeding. In the cases reported the diagnosis was performed only via intra-operative enteroscopy. An unusual conservative surgical treatment was performed based on ligation of the vascular elements of the angiodysplasia. This method makes it possible to avoid an intestinal resection and yelds good results.

Squamous and adenosquamous cell carcinomas of the gallbladder.

Squamous and adenosquamous cell carcinomas (ASC and SCC) are rare subtypes of gallbladder cancer, traditionally considered more aggressive and with a poorer prognosis than adenocarcinoma. We report about two patients affected by an advanced squamous cell carcinoma of the gallbladder. Both had a large tumour in the gallbladder fossa region with infiltration of the liver. Surgical resection was radical in one, but palliative in the other. pTNM was T3 N0 M0, G3, R0 in the former and T3 N0 M0, G2 R1 in the latter. Patients died for local recurrence after 12 and 5 months, respectively. Natural history, clinical findings, prognosis and outcome of this rare gallbladder tumour are discussed on the basis of a review of the English literature. In conclusion, an aggressive and radical surgical treatment of advanced squamous and adenosquamous cell gallbladder carcinomas seems to be indicated for their low proclivity to distant spreading.

Mechanical small bowel obstruction due to an inflamed appendix wrapping around the last loop of ileum.

Acute apendicitis rarely presents with a clinical picture of mechanical small-bowel obstruction. The Authors report a case of this inusual clinical occurrence, arised like a complication of a common disease, characterized by a chronically inflamed appendix (mucocele) wrapping around the last loop of ileum that produced volvolus and strangulation. The few similar cases reported in the literature are moreover reviewed.

Intestinal anisakiasis in Italy: a case treated by emergency surgery.

Anisakiasis is a fish-borne zoonotic disease. A case of intestinal anisakiasis in a woman who had consumed raw marinated anchovies was reported. The intestinal localization resulted in occlusive acute abdomen which required an emergency surgical treatment. The histological examination of the eosinophilic granuloma removed from the resected colon revealed the presence of larval nematodes of the genus Anisakis as causative agents.

Appendicitis and abscess in an adult patient with intestinal nonrotation: Case report.

The aim of the article is showing a particular case of midgut nonrotation. It is a congenital defect of the bowel development, during which fails the rotation of 270° around the vascular pedicle. This anomaly causes a different intestinal arrangement: the small bowel is located in the right side of abdominal cavity while the large bowel is situated in the left side. We present a case of acute appendicitis and abscess treated successfully with urgent surgical intervention in a patient completely asymptomatic for nonrotation. Nonrotation may lead to acute symptoms, vague abdominal pain or may remain asymptomatic throughout all life and be discovered only accidentally. Radiological exams and laparoscopy can help to make a correct diagnosis. A conservative treatment could be preferred in asymptomatic patients and Ladd's surgical procedure should be performed in selected cases.

TNM staging in lung cancer: role of computed tomography.

Current procedures to determine the clinical staging of disease in patients with lung cancer are lacking in accuracy, particularly regarding the presence of metastatic disease. We have evaluated the use of computed tomography (CT) of the chest, brain, and upper abdomen for clinical staging of the extent of disease in 113 consecutive patients with histologically confirmed carcinoma of the lung. Comparisons with mediastinoscopy and surgical findings were made regarding the extent of primary tumor in 47 patients and nodal involvement in 41 patients. The CT scan showed a sensitivity of 86.9%, a specificity of 91.6%, and an accuracy of 89.3% for extrapulmonary extension of the primary tumor and a sensitivity of 50%, a specificity of 96.5% and an accuracy of 82.9% for mediastinal node involvement. Thirty-two of the 85 patients studied by total body CT scan had distant metastasis, of which 24 (75%) were clinically silent. Thus 28.2% of the 85 patients studied had asymptomatic metastatic disease. We conclude that CT of the chest, brain, and upper abdomen is a reliable procedure for staging lung cancer.

Influence of acute cholecystitis on surgical strategy and outcome of inapparent carcinoma of the gallbladder: a report on two cases.

Unsuspected microscopic adenocarcinoma (T1) of the gallbladder was identified after surgery in two patients who underwent urgent open cholecystectomy for acute cholecystitis. In spite of the tumor being at an early stage both patients died after few months for local and disseminated tumor recurrence. The influence of the associated inflammatory disease of the gallbladder on the outcome of patients with inapparent gallbladder carcinoma is discussed and a more aggressive surgical strategy is suggested.

Inferior vena cava involvement by a left side adrenocortical carcinoma: operative and prognostic considerations.

We report the fifth case of neoplastic involvement of the infrahepatic portion of the inferior vena cava, observed in a young woman affected by a left adrenal cortical carcinoma. The intracaval extension of a neoplastic thrombus from an adrenal tumor is a rare complication that should not be considered a dismal prognostic factor and does not contraindicate tumor resection with curative intent. Caval invasion must be preoperatively investigated to plan the correct surgical access and avoid the risk of neoplastic embolization.

Influence of blunt needles on surgical glove perforation and safety for the surgeon.

BACKGROUND: Round-tipped blunt needle (BN) may decrease the risk of needlestick injuries and hand contamination. We prospectively determined the incidence of glove perforations in emergency abdominal procedures and the efficacy of BN in increasing the safety for surgeons. METHODS: Two hundred patients were randomized to undergo closure of the abdominal fascia using sharp needle (SN) or BN. Gloves were tested at the end of the procedure. RESULTS: Surgeons had 14 needlestick injuries and 76 perforations recorded in 69 pair of gloves. Sharp needles were responsible for all injuries and 58 (76%) perforations (P < 0.00004 and P < 0.00001, respectively). This difference was still higher when considering the perforations related to the abdominal fascia closure (BN 7% versus SN 50%; P < 0.0006). CONCLUSION: The risk of glove perforation is sevenfold greater if SN are used. Blunt needles reduce sharp injuries and improve safety for surgeons.

[Bronchopulmonary carcinoma: influence of type of resection on long term survival]. / Il carcinoma broncopolmonare: influenza del tipo di resezione sulla sopravvivenza a distanza.

A statistical comparison between survival and type of resection: Lobectomy and pneumonectomy was made out of 108 patients who had undergone curative resection for lung cancer (with a minimum 3 years follow-up). Analysis was first made on the whole series, then the patients were classified according to histological type (W-PL) or staging (TNM) and finally stratified in 2 control levels (stage and histological type). There was a better prognosis for lobectomy than for pneumonectomy, referring to a single subgroup, but not in a statistically significant way. There was a better prognosis for patients who had been operated for lobectomy S(2) 2 LOB with a 36 months survival for 85%. There were better results for squamous cell carcinoma stage I and II S(2) 1 PNE, for those patients who had been operated for pneumonectomy with a median survival of 32 months and over 3 years survival for 41.7%.

Role of delayed cutaneous hypersensitivity reaction in classifying patients with bronchial carcinoma.

Cell-mediated immune response was evaluated in 150 patients with histologically confirmed bronchopulmonary carcinoma using bacterial and fungal recall antigens injected intradermally (PPD, candida, trichophyton). In the study group negative skin test reaction was found in 51 of 150 patients (34.0%), whereas in the control population it was found in 5 of 33 cases (15.1%) (p less than 0.05). Histologic cell type and stage of disease were defined for each patient. It was possible to calculate the growth rate of the primary tumor only in 68 of 150 patients, and it was recorded as doubling time. Evaluation of the skin test reaction in each prognostic subgroup showed no statistically significant differences. The only statistically significant differences were found when each prognostic subgroup was compared with the control population according to the frequency of a negative response to the skin test, particularly in stage III M1 (p less than 0.05) and stage III M0 (p less than 0.02). The delayed cutaneous hypersensitivity studied with recall antigen stimulation was mainly correlated with the stage of disease, and it should not be considered as an independent prognostic factor.

A new multiparametric classification in lung cancer patients - S.M.I.G.

The classification of bronchogenic carcinoma as a function of the prognosis is still an open field. The evaluation of stage, by use of the TNM system, and histologic cell type is not sufficient to guarantee a correct prognosis. The growth rate of the neoplasm is another important parameter. We propose a classification that takes into account the stage (S), histologic cell type (M), immune status (I) and the growth rate of the primary tumor (G): S.M.I.G. We studied 90 lung cancer patients according to the S.M.I.G. classification and we observed that their prognoses were directly correlated with their S.M.I.G. scores (the higher the score, the higher the 10-month mortality rate). The mortality rates within the first 10 months of follow-up were respectively 0%, 0%, 36.36%, 68%, 90.9% for the 5 groups obtained by S.M.I.G. The difference is statistically significant (P less than 0.0075) and there is a linear correlation between the mortality rate and the score assigned to each group (R = 0.943; P less than 0.05). The S.M.I.G. classification can predict the prognosis more efficiently than the usual classification (TNM) and histological cell type.

Management of abdominal aortic prosthetic graft infection requiring emergent treatment.

The purpose of this study was to investigate mortality and morbidity rates and long-term outcome of patients who underwent emergency treatment of abdominal aortic prosthetic graft infection. Between January 1984 and December 1993, 18 men aged fifty-nine +/- sixteen years were operated on as an emergency for an acute life-threatening complication of aortic prosthetic graft infection. The grafts had been implanted for abdominal aortic aneurysm in 9 patients and aortoiliac occlusive disease in 9, from one to one hundred seventy months previously. Five (28%) patients presented with a hemorrhagic shock due to a fistula between the vascular reconstruction and the small bowel (4 patients) or the right ureter (1 patient) and 13 (72%) had generalized sepsis. The grafts were always radically explanted. Extraanatomic revascularization procedures included 6 axillopopliteal and 12 axillofemoral bypass grafts. Operative mortality was 39% (7 patients), and 3 (9%) limbs were amputated within thirty days. Two (11%) patients died after seven and twelve months, respectively, of septic complications, and 1 (5%) patient died after six months from an unrelated cause. Eight (73%) patients are still alive at a mean follow-up of fifty +/- thirty-four months, but in 3 the extraanatomic bypass was removed for infection and 5 major amputations were performed. Two-year survival and limb salvage rates were 44% and 50%, respectively. Aortic prosthetic graft infections that require emergent treatment continue to demonstrate high early and late mortality and limb loss rates despite aggressive intervention and limb salvage procedures. Newer methods of managing these complications should continue to be investigated.