Acute intestinal ischemia in patients with COVID-19: single-centre experience and literature review.

OBJECTIVE: Acute Intestinal ischemia (AII) may involve the small and/or large bowel after any process affecting intestinal blood flow. COVID-19-related gastrointestinal manifestations, including AII, have been attributed to pharmacologic effects, metabolic disorders in ICU patients and other opportunistic colonic pathogens. AII in COVID-19 patients may be due also to "viral enteropathy" and  SARS-CoV-2-induced small vessel thrombosis. A critical appraisal of personal experience regarding COVID-19 and AII was carried out comparing this with a systematic literature review of published series. PATIENTS AND METHODS:   A retrospective observational clinical cohort study and a systematic literature review including only COVID-19 positive patients with acute arterial or venous intestinal ischemia were performed. The primary endpoint of the study was the mortality rate. Secondary endpoints were occurrence of major complications and length of hospital stay. RESULTS: Patient mean age was 62.9±14.9, with a prevalence of male gender (23 male, 72% vs. 9 female, 28%). The mean Charlson Comorbidity Index was 3.1±2.7. Surgery was performed in 24/32 patients (75.0%), with a mean delay time from admission to surgery of 6.0 ±5.6 days. Small bowel ischemia was confirmed to be the most common finding at surgical exploration (22/24, 91.7%). Acute abdomen at admission to the ED (Group 1) was observed in 10 (31.2%) cases, while 16 (50%) patients developed an acute abdomen condition during hospitalization (Group 2) for SARS-CoV-2 infection. CONCLUSIONS: Our literature review showed how intestinal ischemia in patients with SARS-CoV-2 has been reported all over the world. The majority of the patients have a high CCI with multiple comorbidities, above all hypertension and cardiovascular disease. GI symptoms were not always present at the admission. A high level of suspicion for intestinal ischemia should be maintained in COVID-19 patients presenting with GI symptoms or with incremental abdominal pain. Nevertheless, a prompt thromboelastogram and laboratory test may confirm the need of improving and fastening the use of anticoagulants and trigger an extended indication for early abdominal CECT in patients with suggestive symptoms or biochemical markers of intestinal ischemia.

Preoperative chemoradiotherapy affects postoperative outcomes and functional results in patients treated with transanal endoscopic microsurgery for rectal neoplasms.

BACKGROUND: The aim of this study was to quantify the incidence of short-term postoperative complications and functional disorders at 1 year from transanal endoscopic microsurgery (TEM) for rectal neoplasms, to compare patients treated with TEM alone and with TEM after preoperative chemoradiotherapy (CRT) and to analyse factors influencing postoperative morbidity and functional outcomes. METHODS: A retrospective study was conducted on all patients treated with TEM for rectal neoplasms at our institution in January 2000-December 2017. Data from a prospectively maintained database were retrospectively analysed. Patients were divided into two groups: adenoma or early rectal cancer (no CRT group) and locally advanced extraperitoneal rectal cancer with major or complete clinical response after preoperative CRT (CRT group). Short-term postoperative mortality and morbidity and the functional results at 1 year were recorded. The two groups were compared, and a statistical analysis of factors influencing postoperative morbidity and functional outcomes was performed. Functional outcome was also evaluated with the low anterior resection syndrome (LARS) score (0-20 no LARS, 21-29 minor LARS and 30-42 major LARS). RESULTS: One hundred and thirteen patients (71 males, 42 females, median age 64 years [range 41-80 years]) were included in the study (46 in the CRT group). The overall postoperative complication rate was 23.0%, lower in the noCRT group (p < 0.001), but only 2.7% were grade ≥ 3. The most frequent complication was suture dehiscence (17.6%), which occurred less frequently in the noCRT group (p < 0.001). At 1 year from TEM, the most frequent symptoms was urgency (11.9%, without significant differences between the CRT group and the noCRT group); the noCRT group experienced a lower rate of soiling than the CRT group (0% vs. 7.7%; p: 0.027). The incidence of LARS was evaluated in 47 patients from May 2012 on and was 21.3% occurring less frequently in the noCRT group (10% vs. 41.2%; p: 0.012). Only 6.4% of the patients evaluated experienced major LARS. In multivariate analysis, preoperative CRT significantly worsened postoperative morbidity and functional outcomes. CONCLUSIONS: TEM is a safe procedure associated with only low risk of severe postoperative complications and major LARS. Preoperative CRT seems to increase the rate of postoperative morbidity after TEM and led to worse functional outcomes at 1 year after surgery.

Redo-laparoscopy in the management of complications after laparoscopic colorectal surgery: a systematic review and meta-analysis of surgical outcomes.

BACKGROUND: The laparoscopic approach for colorectal surgery has gradually become widely accepted for the treatment of both benign and malignant diseases thanks to its several advantages over the open approach. However, it is associated with the same potential postoperative complications. Some recent studies have analyzed the potential role of laparoscopy in early diagnosis and management of complications following laparoscopic colorectal surgery. The aim of this systematic review was to investigate the outcomes of redo-laparoscopy (RL) for the management of early postoperative complications following laparoscopic colorectal surgery, focusing on length of stay, morbidity and mortality. METHODS: A systematic review of the literature was performed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines through MEDLINE (PubMed), Embase and Google Scholar from January 1990 to December 2019. The main outcomes examined were conversion rate, length of hospital stay, postoperative morbidity and mortality rates. A meta-analysis of all eligible studies was then conducted and forest plots were generated. RESULTS: A total of 19 studies involving 1394 patients who required reoperation after laparoscopic colorectal resection were included. In 539 (38.2%) of these patients, a laparoscopic approach was adopted. The most common indication for returning to the operating theater was anastomotic leakage (64.4% of all redo-surgeries, 67.7% of RL) and the most common type of intervention performed in RL was diverting stoma with or without anastomotic repair/redo (47.1%). Nine studies were included in the pooled analysis. The mean length of stay was significantly shorter in the RL group than in the redo-open one (WMD = - 0.90; 95% CI - 1.04 to - 0.76; Z = - 12,6; p < 0.001). A significantly lower risk of mortality was observed in the RL cohort (OR = - 0.91; 95% CI - 1.58 to - 0.23; Z = - 2.62; p = 0.009). CONCLUSIONS: Laparoscopy is a valid and effective approach for the treatment of complications following laparoscopic primary colorectal surgery thanks to it is well-established advantages over the open approach, which remain noticeable even in redo-surgeries.

Hospital environment hygiene nurse: a key player to reduce healthcare associated infections by multi-resistant organisms.

BACKGROUND: Multi-Resistant Organisms (MRO) healthcare-associated infections (HAI) are closely associated with contamination of surfaces. Outsourced companies are usually in charge of both hospital hygiene and environmental hygiene personnel (EHP) supervision, which can result in bias. METHODS: A quasi-experimental study. The intervention was to add the "Hospital Environment Hygiene Nurse" (HEHN). MRO acquired infection rate and MRO acquired colonized rate were calculated, pre and post intervention. Confounding variables: MRO carriage rate upon admission and hospitalisation days median (HDM) were calculated. RESULTS: Median length of stay: 5 days (p=0.85, interquartile range=6 days). Carriage rate upon admission: 4.3% for pre-intervention vs 5.3% post-intervention, dif. (CI 95%): 1% (-1% to 2.9%) p=0.33. MRO acquired infection rate: 4.3% for pre-intervention vs. 2% post-intervention, Standardized Infection Ratio (SIR) (CI 95%): 0.47 (0.25 to 0.87). MRO acquired colonization rate:10.4% for pre-intervention vs. 7.9% post-intervention, SIR (CI 95%): 0.75 (0.53 to 1.07). CONCLUSIONS: As a reinforcement to standard infection control (IC) measures in place, the incorporation of an exclusive, full-time HEHN was significantly useful to reduce MRO HAI.

Traumatismo de alta velocidad por arma de fuego en zona de conflicto / High velocity trauma by gunshot in conflict área

Presentamos el caso de una baja por arma de fuego ingresada en el Role 2E español de Herat (Afganistán) analizando el diagnóstico, tratamiento y evacuación en el teatro de operaciones

We present a case of a casualty by gunshot who was admitted in Spanish Role 2E (Herat –Afghanistan-) showing the diagnosis, treatment and evacuation in the theatre

Orbital exenteration in elderly patients: personal experience.

Orbital exenteration is a disfiguring procedure which typically involves removal of the entire contents of the orbit including the periorbita, appendages, eyelids and, sometimes, a varying amount of surrounding skin. This operation is reserved for the treatment of potentially life-threatening malignancies arising from the orbit, paranasal sinuses or periocular skin. The marked increase in the average life span and resulting greater incidence of invasive malignant skin tumours of the face, typical of old age, is the reason for the increased rate of exenterations in elderly patients. The purpose of this report is to describe personal experience regarding 8 operations of orbital exenteration carried out on elderly patients, 6 males and 2 females, age range 66-85 years (mean 75), who came to our observation, from January 2002 to December 2007, on account of cancer (7 cases: 4 basal cell carcinomas; 1 squamous cell carcinoma; 1 fibrosarcoma; 1 melanoma) or infectious inflammatory disease (1 case of rhinocerebral mucormycosis) and were treated with type III orbital exenteration (2 cases) and type IV orbital exenteration (6 cases according to Meyer and Zaoli's classification). The methods used to reconstruct the eye-socket consisted of a full-thickness skin graft in 5 cases, pedicled myocutaneous flaps in 2 cases--a latissimus dorsi muscle flap alone, in one patient, and combined with a pectoralis major muscle flap in another - and a combined lateral-based frontal fasciocutaneous pedicled flap and full-thickness skin graft in the oldest patient. Regarding survival and the local clinical situation, 3 of the 4 patients with basal cell carcinomas are alive and disease-free after 6 years, 2 years and 20 months, respectively, while the oldest patient died of the disease after 10 months. The subject who underwent surgery for squamous cell carcinoma is alive and disease-free after 2 years. The patients with melanoma, fibrosarcoma and mucormycosis died. Although there are various options available for reconstruction, full-thickness skin graft or a pedicled muscolocutaneous flap provide the simplest solution in the elderly population with significant co-morbidities. The final outcome is, in our experience, comparable to that of more complex flap reconstruction, obtaining very good final results with minimal donor site morbility and a reduced operation time.

Parotid surgery in patients over seventy-five years old.

Malignant parotid tumours are generally rare but become more common in the last decades of life; this increased incidence concerns mainly secondary parotid space involvement from metastasis or direct invasion. During the past five years, we observed and operated upon 84 patients for parotid diseases, performing 86 parotidectomies (2 bilateral operations). The patients included 30 (35.7%) over 75 years old (2 subjects over 90), mean age 80.5 years, object of the present study. In these 30 patients 2 chronic infections were observed, 6 benign tumours and 22 malignant tumours with only 6 primary neoplastic lesions. Overall, 14 extended radical parotidectomies were performed, 13 conservative total parotidectomies, 2 superficial parotidectomies and 1 radical parotidectomy, a few associated with neck dissection and/or radiotherapy. Three patients died in the post-operative period from heart attack. Five patients died from disease (3 from melanomas--2 after 3 years and 1 after 2 years--and 2 from primary carcinomas--1 after 2 years and 1 after 1 year). Six patients died without disease from various causes (2 after 4 years, the others after 3, 2, 1 year and 8 months). Nine patients are alive, 8 NED and 1 with disease in the ethmoid after 2 years, the latter well under control with radiotherapy. This experience implies that surgical treatment of these secondary tumours, which are performed more frequently in old age, exposes the patient to the risk of serious complications (3 patients died in the immediate post-operative period) and stresses the importance of careful evaluation of general conditions. However, surgery seems to have been the treatment indicated also in the patients who subsequently died from the disease, but in whom at least two-year survival was achieved in almost all cases. Unfortunately, because of the advanced age of the patients, the final results are penalized by deaths from natural causes. It is, nevertheless, encouraging that over one third of the patients operated upon are free of disease.

Acute myositis in a patient with systemic sclerosis after the administration of darbepoetin alpha.

We first describe the onset of acute myositis in a patient suffering from systemic sclerosis after the administration of darbepoetin alpha for renal failure-related anemia. Therapeutic implications and risks are discussed.

Effects of an appropriate oral diet on the nutritional status of patients with HCV-related liver cirrhosis: a prospective study.

BACKGROUND AND AIMS: In patients with liver cirrhosis, protein-energy malnutrition is a frequent finding and a risk factor influencing survival. The aim was to estimate the effects of an adequate diet on malnutrition and clinical outcome in patients with Child A or B HCV-related liver cirrhosis. METHODS: We enrolled 90 consecutive outpatients (M/F=52/38) with liver cirrhosis, 30 in Child class A and 60 in class B. Patients were evaluated by anamnesis, clinical examination, estimation of daily caloric intake and measurement of anthropometrical and biochemical indexes. Patients were randomized into two groups: group 1 with a 3-month oral controlled diet started one week after the first examination and this was followed by a 3-month of spontaneous dietary intake, and group 2 which started a 3-month spontaneous dietary intake followed by a 3-month of controlled diet. The follow-up was performed every month. RESULTS: During the period of controlled diet in patients of both groups, protein malnutrition assessed by midarm muscle circumference, creatinine-height index and serum albumin significantly improved independently of the Child class. Lipid malnutrition, assessed by triceps skin fold thickness values, did not improve during the course of the study. The compliance to the prescribed diet was very high in both groups, and no carry over effect of the previous dietary intake was observed during the follow-up period. CONCLUSIONS: The results emphasize the importance of both nutritional status evaluation and improvement in the Child A and B cirrhotic patients with HCV-related disease. The proposed nutritional approach was able to influence their protein malnutrition positively.

A life-threatening case of stenosing pill hypopharynx-oesophagitis caused by a tamsulosin capsule.

Pill oesophagitis is a frequent clinical entity that may induce dysphagia and exceptionally oesophageal occlusion. The mechanisms inducing mucosal inflammation are not completely defined, but oesophageal damage occurring when the caustic content of a drug remains in the oesophagus long enough to produce mucosal lesions seems to be a main factor. We report a case of a life-threatening stenosing pill hypopharynx-oesophagitis caused by the ingestion of a capsule of tamsulosin, a drug diffusely used for benign prostatic hyperplasia treatment.

Osteoma of maxillary sinus: case report.

Cranio-facial osteomas are frequent in the nasal and paranasal sinuses, particularly in fronto-ethmoidal sites; other sinus cavities are more rarely affected. Although various theories (embryogenetic, traumatic and inflammatory) have been advanced to explain the pathogenesis, it is difficult to establish a specific cause-effect relationship. Nasal and paranasal osteomas are generally asymptomatic and are diagnosed on the basis of X-rays performed for other conditions, the onset of sinusitis-like symptoms or the appearance of complications due to sinus diseases. These cases require surgical removal to avoid the risk of short- or long-term complications or to solve any that may already exist. Herein, a rare case of osteoma of the maxillary sinus is described and the possible aetiopathogenetic role of traumatic and inflammatory factors described. The main clinical and therapeutic data concerning this lesion are examined.

Thyroid function studies in patients with cancer of the larynx: preliminary evaluation.

OBJECTIVE: Our goal was to evaluate thyroid function before and after surgery only or radiotherapy plus surgery for laryngeal neoplasms. STUDY DESIGN AND SETTING: The study group consisted of a total of 30 patients with laryngeal cancer (22 treated with surgery only and 8 treated with surgery plus radiotherapy) who were evaluated by ultrasensitive thyroid-stimulating hormone, free T4, and antithyroid antibodies both preoperatively and at 6 and 12 months after surgery. RESULTS: All patients had normal thyroid function before treatment (1 patient had elevated antithyroid autoantibodies); after 1 year, 4 (13.34%) patients were hypothyroid. In 3 patients, it was subclinical (ie, elevated thyroid-stimulating hormone with normal free T4), and in 1 patient, it was symptomatic. CONCLUSION: Our preliminary data suggest that hypothyroidism occurs in a small but substantial proportion of patients undergoing surgery with or without adjuvant radiotherapy for laryngeal cancer. SIGNIFICANCE: Thyroid hormone dosing should be routinely included in the assessment of patients with laryngeal cancer, because it is simple and inexpensive and may allow the early diagnosis and management of hypothyroidism.

Hepatic and splenic amyloidosis: dual-phase spiral CT findings.

Although the liver and spleen are frequently involved in primary systemic amyloidosis, the clinical manifestations of hepatic and splenic involvement are usually mild and a dominant symptomatic hepatic presentation is uncommon. We report a case of a 51-year-old woman with giant hepatomegaly, hypertransaminasemia, increase in alkaline phosphatase, and ascites, in whom the findings of dual-phase spiral computed tomography suggested liver and splenic amyloidosis.

Continuing validity of pectoralis major muscle flap 25 years after its first application.

Surgical treatment of malignant cervico-facial tumours often includes vast demolition of mucosal, cutaneous, muscle and bone tissues, requiring immediate repair of the extensive loss of substance with reconstructive pedicled or revascularised free flaps. Still today, when it is not necessary to reconstruct the mandibular bone or in particular clinical situations as found in patients in whom microsurgery is contraindicated due to general conditions or in those cases of unsuccessful microsurgical flaps, use of the pedicled flaps is still indicated, particularly the myocutaneous flap of the major pectoral muscle described approximately 25 years ago, and quite rightly referred to as "work horse" or "spare wheel" of reconstructive surgery. Study population comprises 33 patients (27 male, 6 female, mean age: 61 years, range: 36-86) observed between 2000-2002. These patients were submitted to demolitive surgery on account of malignant cervico-facial neoplasias. The role of the major pectoral muscle pedicled flap is emphasised stressing that resection of the pedicle, even a few weeks after transplant, together with the subclavicular passage, may avoid the majority of the well-known functional and aesthetic problems related to this reparative technique.

[Surgical treatment of malignant lip tumors. Personal experience]. / Il trattamento chirurgico dei tumori maligni del labbro. Esperienza personale.

The malignant tumours of the lip account for nearly 1-2% of the cervicofacial neoplasms. These lesions are frequently spinous cell carcinomas and basal cell carcinomas (25% of all oral cancers). The spinous cell carcinoma is mainly located in the lower lip, the basal cell carcinoma is more common in the upper lip. The incidence of lip cancer in males is much high than in females. The etiopathogenesis of these lesions is connected with exposure to sun, smoking, genetics predisposition (mutation of the p53 suppressor factor) and with the evolution of precancerous lesions (radiodermatitis, chronic cheilitis, xeroderma pigmentosum). Some Authors emphasized the viral etiopathogenesis: HPV16, HPV24, HSV1, HSV2. The treatment of lip carcinoma is surgical: excision and reconstruction. The numerous reconstructive techniques are mostly the cutaneous local sliding flaps and the rotation flaps. The lip reconstruction require a remarkable diligence for preserve, as much possible, the shape and functions of lip. The Authors report their experience about the surgical treatment of 19 patients with lip carcinoma (16 spinous cell carcinomas, 3 basal cell carcinomas) and describe the main surgical reconstructive techniques to preserve the feeding, phonation and mimic expression.

Primary Kaposi sarcoma of the bowel in a HIV-negative patient.

A case of Kaposi sarcoma with HIV-negative and sequence of HHV-8 positive and exclusive rectosigmoid and descending colon involvement without immunodeficiency is reported. Histologically, in addition to typical features of Kaposi sarcoma, Cowdry type A inclusions were seen. PCR analysis of the tumor showed positivity for human herpesvirus 8. Two of the six reported cases of Kaposi sarcoma limited to the bowel were from African men before the AIDS epidemic. J. Surg. Oncol. 2001;76:197-200.

Oral glutamine in the prevention of fluorouracil induced intestinal toxicity: a double blind, placebo controlled, randomised trial.

BACKGROUND: 5-Fluorouracil (FU) in association with folinic acid (FA) is the most frequently used chemotherapeutic agent in colorectal cancer but it often causes diarrhoea. Animal and human studies suggest that glutamine stimulates intestinal mucosal growth. AIM: To determine if oral glutamine prevents changes in intestinal absorption (IA) and permeability (IP) induced by FU/FA. METHODS: Seventy chemotherapy naive patients with colorectal cancer were randomly assigned to oral glutamine (18 g/day) or placebo before the first cycle of FU (450 mg/m(2)) and FA (100 mg/m(2)) administered intravenously for five days. Treatment was continued for 15 days, starting five days before the beginning of chemotherapy. IA (D-xylose urinary excretion) and IP (cellobiose-mannitol test) were assessed at baseline and four and five days after the end of the first cycle of chemotherapy, respectively. Patients kept a daily record of diarrhoea, scored using the classification system of the National Cancer Institute (Bethesda, Maryland, USA). Duration of diarrhoea was recorded and the area under the curve (AUC) was calculated for each patient. RESULTS: Baseline patient characteristics and basal values of IP and IA tests were similar in the two arms. After one cycle of chemotherapy, the reduction in IA (D-xylose absorption) was more marked in the placebo arm (7.1% v 3. 8%; p=0.02); reduction of IP to mannitol was higher in the placebo arm (9.2% v 4.5%; p=0.02); and urinary recovery of cellobiose was not different between the study arms (p=0.60). Accordingly, the cellobiose-mannitol ratio increased more in the placebo arm (0.037 v 0.012; p=0.04). Average AUC of diarrhoea (1.9 v 4.5; p=0.09) and average number of loperamide tablets taken (0.4 v 2.6; p=0.002) were reduced in the glutamine arm. CONCLUSIONS: Glutamine reduces changes in IA and IP induced by FU and may have a protective effect on FU induced diarrhoea.