Appendectomy versus conservative treatment with antibiotics for patients with uncomplicated acute appendicitis: a propensity score-matched analysis of patient-centered outcomes (the ACTUAA prospective multicenter trial).

PURPOSE: The aim of this prospective multicenter study was to compare antibiotic therapy and appendectomy as treatment for patients with uncomplicated appendicitis confirmed by ultrasound and/or computed tomography. METHODS: The study was conducted from January 2017 to January 2018. Data regarding all patients discharged from the participating centers with a diagnosis of uncomplicated appendicitis were collected prospectively. RESULTS: Of the 318 patients enrolled in the study, 27.4% underwent antibiotic-first therapy, and 72.6% underwent appendectomy. The matched group was composed of 87 patients in both study arms. Of the 87 patients available of 1-year follow-up in the antibiotic-first group, 64 (73.6%) did not require appendectomy. The complication-free treatment success in the antibiotic-first group was 64.4%. A statistically significant higher complication-free treatment success was found in the appendectomy group: 81.8% in the pre-matching sample and 83.9% in the post-matching sample. Patients in the antibiotic-first group reported lower VAS scores compared to those treated with an appendectomy, both at discharge (2.0 ± 1.7 vs 3.6 ± 2.3) and at 30-day follow-up (0.3 ± 0.6 vs 2.1 ± 1.7). The mean of the days of absence from work was higher in the appendectomy group (ß 0.63; 95% CI 0.08-1.18). CONCLUSION: Although laparoscopic appendectomy remains the gold standard of treatment for uncomplicated appendicitis, conservative treatment with antibiotics is a safe option in most cases. Approximately 65% of patients treated with antibiotics are symptom-free at 1 year, without increased risk of adverse events should symptoms recur, and better outcomes in terms of less pain and shorter period of absence from work compared to patients undergoing an appendectomy. TRIAL REGISTRATION: Clinicaltrials.gov identifier (NCT number): NCT03080103.

Predictive Factors of Intestinal Necrosis in Acute Mesenteric Ischemia.

OBJECTIVES: Acute mesenteric ischemia (AMI) is a gastrointestinal and vascular emergency in which the detection of patients requiring intestinal resection is mandatory. METHODS: Registered data of 55 consecutive patients admitted to our center between January 2010 and December 2016 that underwent an explorative laparotomy for a suspected diagnosis of irreversible transmural intestinal necrosis (ITIN) were analyzed. Demographic, clinical, laboratory and CT findings were statistically analyzed in order to search predictive factors of ITIN and their correlation to its clinical spectre. RESULTS: Tobacco use was the most statistically significant (p<0.01) cardiovascular disease risk factor involved in ITIN. Among lab tests, Serum lactate levels ˃ 2mmol/L resulted in a statistically significant association with ITIN (p=0.0001). Organ failure (defined as Marshall score> 2) and the three main CT findings (decreased bowel wall enhancement, bowel loop dilation and demonstrated vessel occlusion) were strongly associated with ITIN (p values: 0.001, 0.007, 0.0013, 0.0005). Only serum lactate levels>2 mmol/L resulted as statistically significant as predictive factors of ITIN in multivariate analysis using logistic regression (OR 49.66 and p-value 0.0021). CONCLUSION: Our univariate and multivariate analysis identified multiple factors (Serum lactate levels ˃ 2mmol/L, Organ failure, CT signs) that could suggest patients that require a surgical approach for ITIN.

Efficacy and safety of ultrasound-guided placement of central venous port systems via the right internal jugular vein in elderly oncologic patients: our single-center experience and protocol.

BACKGROUND: Ultrasound-guidance has become the routine method for internal jugular vein (IJV) catheterization reducing dramatically failure and complication rates for central venous port (CVP) placement. AIMS: The aim of this study was to determine the safety and efficacy of ultrasound-guided IJV CVP placement in elderly oncologic patients. METHODS: Between January 2013 and December 2015, 101 elderly oncological patients underwent right IJV CVP placement under ultrasound-guidance. The length of catheter introduction ranged from 18 to 21 cm. Intraoperative fluoroscopy (IF) was always performed intraoperatively. Chest X-ray (CXR) was always performed 30 min after the end of the procedure. RESULTS: The morbidity rate was 1.98%; two arterial punctures were reported with one self-limiting hematoma. Two patients (1.98%) had catheter misplacements, recognized by intraoperative IF. No patients (0%) experienced pneumothorax (PNX), confirmed at CXR. Patients were all discharged at maximum 6 h from the procedure. DISCUSSION: The risk of catheter misplacement, PNX, and arterial/nerve puncture remains present with this technique. Lower rates of catheter misplacement have been reported after right IJV puncture, probably for its straight vertical course. Our results are in accordance with literature (1 counter-lateral subclavian vein and 1 counter-lateral internal jugular vein misplacements). All misplacements were detected intraoperatively. The PNX rates after cannulation of the IJV vary between 0.0 and 0.5%. We had no PNX occurrence. CONCLUSION: Ultrasonography (US) has improved safety and effectiveness of port system placements. While routine post-procedural CXR seems avoidable, IF should be considered mandatory.

Bilateral benign multinodular goiter: What is the adequate surgical therapy? A review of literature.

BACKGROUND: Benign multinodular goiter (BMNG) is the most common endocrine disease requiring surgery. During the last few years a more aggressive approach has become the trend for bilateral BMNG treatment. METHOD: Randomized clinical trials of any size that compared bilateral subtotal resection, Dunhill procedure and total thyroidectomy for benign multinodular goiter, published between January 2000 and the end of March 2015, were reviewed. DISCUSSION: Total thyroidectomy can be considered the most reliable approach in preventing recurrence. The Dunhill procedure is related to a higher rate of recurrence, but rarely recurrences after Dunhill procedure lead to reoperation. Total thyroidectomy avoid completion thyroidectomy for incidental carcinoma and its related risks. Recurrent laryngeal nerve (RLN) palsy becomes less common as surgical experience increases. Transient and permanent hypoparathyroidism is strictly related to the extent of neck dissection. In the risk-cost analysis we must consider the type of patient candidated to surgery and the impact of the surgical protocol we apply. When thyroid surgery is taken in consideration, specific complication rates of different procedures in each hospital must be analyzed accordingly to patient-specific risk factors and local expertise. CONCLUSION: The Dunhill procedure seems to be a good compromise between radicality and prevention of complications, avoiding reoperation for recurrence or completion thyroidectomy for incidental thyroid carcinoma. More follow-up studies and prospective studies are necessary to better evaluate, definitively, whether to prefer total thyroidectomy or Dunhill procedure in case of benign goiter surgery.

GERD in elderly patients: surgical treatment with Nissen-Rossetti laparoscopic technique, outcome.

BACKGROUND: The gastro-esophageal reflux disease (GERD) is one of the most frequent disease of the upper gastro-entheric tract. Surgical treatment is reserved to selected patients, affected by severe forms of disease and/or without compliance to medical therapy.In 95%-60% of the patients submitted to surgical antireflux intervention, a notable improvement of the quality of life is observed.Functional evaluations performed on pre and post--surgical pHmetric and manometric examination have provided new acquisitions about improvements in the restoration of anatomical and functional integrity of the esophagus-gastric antireflux barrier. METHODS: 45 elderly patients with GERD were recruited in a 27 months period. All patients were subjected to laparoscopic Nissen-Rossetti 360° fundoplication. The subjects had a pre-surgical evaluation with:• 24 hours pHmetry,• esophageal manometry,The same evaluation was repeated 1 month and 6 months after surgical intervention. RESULTS: In our series all patients get benefit from surgical treatment, with an improvement of pHmetric and manometric parameters and a regression of complications of GERD such as Barrett's metaplasia. In 8.33% of patients a PPI therapy was necessary, after the surgical intervention, to control symptoms. CONCLUSIONS: The role of surgery in GERD concerns selected patients. Nissen-Rossetti mini-invasive approach is performed with an acceptable percentage of complications (3%-10%). This technique is associated with a good control of GERD symptoms in a short and middle term and with an improvement of functional parameters, such as pHmetric and manometric.

Morpho-functional gastric pre-and post-operative changes in elderly patients undergoing laparoscopic cholecystectomy for gallstone related disease.

BACKGROUND: Cholecystectomy, gold standard treatment for gallbladder lithiasis, is closely associated with increased bile reflux into the stomach as amply demonstrated by experimental studies. The high prevalence of gallstones in the population and the consequent widespread use of surgical removal of the gallbladder require an assessment of the relationship between cholecystectomy and gastric mucosal disorders.Morphological evaluations performed on serial pre and post - surgical biopsies have provided new acquisitions about gastric damage induced by bile in the organ. METHODS: 62 elderly patients with gallstone related disease were recruited in a 30 months period. All patients were subjected to the most appropriate treatment (Laparoscopic cholecystectomy). The subjects had a pre-surgical evaluation with:• dyspeptic symptoms questionnaire,• gastric endoscopy with body, antrum, and fundus random biopsies,• histo-pathological analysis of samples and elaboration of bile reflux index (BRI).The same evaluation was repeated at a 6 months follow-up. RESULTS: In our series the duodeno-gastric reflux and the consensual biliary gastritis, assessed histologically with the BRI, was found in 58% of the patients after 6 months from cholecystectomy. The demonstrated bile reflux had no effect on H. pylori's gastric colonization nor on the induction of gastric precancerous lesions. CONCLUSIONS: Cholecystectomy, gold standard treatment for gallstone-related diseases, is practiced in a high percentage of patients with this condition. Such procedure, considered by many harmless, was, in our study, associated with a significant risk of developing biliary gastritis after 6 months during the postoperative period.

Diverticular disease hospital cost impact analysis: evaluation of testings and surgical procedures in inpatient and outpatient admissions.

BACKGROUND: Diverticular Disease (DD) is a common condition in Italy and in other western countries. There is not much data concerning DD's impact on budget and activity in hospitals. METHODS: The aim is to detect the clinical workload and the financial impact of diverticular disease in hospitals.Retrospective observational study of all patients treated for diverticular disease during the period of seven years in AOU Federico II. Analysis of inpatient and outpatient investigations, treatment, hospitalization and financial refunds. RESULTS: A total of 738 patients were treated and 840 hospital discharge records were registered. There were a total number of 4101 hospitalization days and 753 outpatient accesses. The investigations generated were 416 endoscopies, 197 abdominal CT scans, 177 abdominal ultrasound scans, 109 X-rays tests. A total of 193 surgical operations were performed. The total cost of this activity was € 1.656.802 or 0.2% of the total budget of the hospital. € 1.346.218, were attributable to the department of general surgery, 0.9% of the department's budget . CONCLUSIONS: The limited impact of diverticular disease on the budget and activity of AOU Federico II of Naples is mainly due to the absence of an emergency department.