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.

Foot infections in diabetes (DFIs) in the out-patient setting: an Italian multicentre observational survey.

AIMS: To conduct a multicentre observational study to describe management of foot infections in diabetes in the out-patient setting in Italy. PATIENTS AND METHODS: Ten centres equally distributed nationwide were asked to collect, by means of a spreadsheet (Access/Excel Microsoft program), data concerning 30 consecutive diabetic patients with foot infections deemed suitable for antibiotic treatment in the out-patient setting. Centres with > or = 5 years' experience of out-patient management were selected. Data from 271 consecutive patients treated as out-patients were collected and analysed by the central coordinator. Statistical analysis was performed using the SPSS statistical software package. RESULTS: Lesions were mainly located at the toes and midfoot (33.6 and 30.2%, respectively); 63 (23.2%) patients had multiple ulcers. Seventy (25.8%) patients also had concomitant osteomyelitis. Three hundred and four pathogens, including Gram-positive and Gram-negative aerobes and anaerobes, were isolated in 219/271 patients (80.8%) by culturing debrided tissue (71.2%) or purulent material (28.8%). Infections were polymicrobial in 33.8% of patients. The most common pathogens were Staphylococcus aureus (27.3%) and Pseudomonas spp. (20.4%); enterobacteriaceae, enterococci, streptococci and anaerobes accounted for 11.5, 7.6, 6.9 and 1.9%, respectively. Antibiotics were frequently administered by parenteral route and frequently in combination. Piperacillin/tazobactam was the parenteral antibiotic most frequently utilized (21.1%). Cure/improvement was observed in 93.4% of patients. CONCLUSIONS: Foot ulcers in diabetes are common and serious; the aetiology is often polymicrobial, often including S. aureus and Pseudomonas spp. Treatment in the out-patient setting is safe and effective, and penicillins together with beta-lactamase inhibitors and fluoroquinolones are the most frequent choice.

ERCP in total situs viscerum inversus.

A 69-year-old cholecystectomized female with known total situs viscerum inversus presented recurrent colicky pain in the left upper abdominal quadrant and jaundice. Laboratory parameters showed increased neutrophils and coniugated bilirubin of 5.53 mg/dl. US and MRCP confirmed total situs viscerum inversus and a dilatation of the intra- and extrahepatic ducts with a peripapillary 13 mm stone. ERCP, sphincterotomy and successful common bile duct stone extraction were performed in the conventional way. ERCP was carried out successfully despite situs inversus maintaining the patient in the prone position with the endoscopist on the right side of the table. Some authors have reported similar cases in whom ERCP was performed in other positions, while this report shows that an experienced endoscopist can achieve the same results in the conventional way as it is possible when anatomical changes, Billroth II or Roux-en-Y, or different positions of the patient, supine or on the left side, are present.

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.

[Lipoma, lipoma-like, atypical lipoma: case report]. / Lipoma, lipoma-like, lipoma atipico: casi clinici.

Lipoma, generally considered as a benign neoplasia, may occur as liposarcoma lipoma-like or atipycal lipoma, especially when of huge dimension. Pathological features of lipoma and liposarcoma lipoma-like are similar: the pattern is characterized by fatty lobules, with fibrosus septa. The presence of vartiable amount of atipical cell with hyperchromatic, solitary or multiple nuclei is suggestive of liposarcoma lipoma-like or atypical lipoma. The clinical features of these lesions are high rate of local recurrence and a low risk to metastasize. Preoperative work up, ultrasounds and MR have a poor diagnostic value, and no imaging features are so specific to differentiate between lipoma and liposarcoma lipoma-like, except site and size. The surgical treatment of the liposarcoma lipoma-like and atypical lipoma and the postoperative therapy, when required, should be performed in specialized centers. Only the combined approach, surgery and radiotherapy, can result in prevention of local recurrence and malignant transformation. The Authors report two cases of liposarcoma lipoma-like admitted to their Institution and review the Literature.

[Early diagnosis importance for a correct surgical treatment of PAES (popliteal artery entrapment syndrome)]. / Importanza di una diagnosi precoce per un corretto trattamento chirurgico della PAES (sindrome da intrappolamento dell'arteria poplitea).

Popliteal artery entrapment syndrome (PAES) is an uncommon pathological entity, caused by segmental popliteal artery compression by the surrounding myofascial structures. Clinical symptoms may appear acutely, with temporary ischaemic attacks, or chronically, with concerned calf claudicatio intermittens and for 30% are bilateral. Diagnosis, besides being based on clinical objectivity (acute and deep pain to the struck limb, mainly during active plantar hyperextension) and history-taking (subject-age and lack of atherosclerosis), is based on ultrasonographic (eco-color Doppler of the aortic-iliac-femural-popliteal trunks, tensiometric Doppler), angio-RM, angio-CT scan and dynamic angiographic exams. Treatment, essentially, is surgical by simple freeing of the popliteal artery from surrounding myofascial structures or by autologous vein (saphenous v.) interposition grafting and patching, or bypass without vessel resection. About clinical case reported by the authors, 44-years female with left calf acute pain symptoms, cold skin by the thermo-touch, hypo-paraesthesia with fifth toe cyanosis and walking inability, surgical treatment, because of precox diagnosis, consisted of simple cut of myofibrous shoot starting from medial head of the left gastrocnemious muscle and compressing popliteal artery, with clinical chart complete resolution.

Acute appendicitis or something else? A case report of cecal endometriosis in emergency setting.

Large Bowel is not uncommonly involved by extra pelvic endometriosis, however cecal localization is the lowest reported in literature; the differential diagnosis of intestinal endometriosis remains difficult, especially in those patients who underwent surgery in emergency setting. The Authors report a case of cecal endometriosis, operated on the basis of clinical signs of surgical abdomen. At laparotomy macroscopic appearance of the cecal lesion, suggesting a neoplastic mass, induced the equip to perform a right emicolectomy. The Authors discuss the clinical features and the role of surgery in management of extra pelvic endometriosis in emergency setting, in the light of the newest advances in medical treatment.

Diabetes and non-traumatic lower extremity amputation in a region of central Italy.

As stated in the St. Vincent Declaration, the reduction of the number of lower extremity amputations (LEA) is one of the major targets in diabetes care. Little information on the prevalence of this complication is available in Italy at present. The aim of this study was to evaluate the impact of diabetes on LEA in a region of central Italy. The regional database of hospital discharge records was used to identify all the cases of non-traumatic LEA (Nt-LEA) that had occurred in 1997 and 1998. Diagnosis of diabetes and the type of surgical intervention were defined on the basis of the medical records. Amputations were categorised as minor or major according to the level of the surgical procedure. The duration of hospitalisation was used to analyse the impact of diabetes on the health care system. Prevalence of diabetes in people who underwent Nt-LEA was 55.9% and it was similar in patients who underwent minor or major amputation (58.7 and 55.0%, respectively). No difference between diabetic and non-diabetic patients was observed as regards sex, level of amputation and duration of hospitalisation. Age was the only predictor of diabetes in amputees. The lack of specific protocols for diabetes foot care or a non-homogeneous application of these protocols in the health care service could account for a similar prevalence of diabetes among patients who underwent minor or major amputation.

[Digestive hemorrhage from a duodenal neuroendocrine tumor. Diagnostic-therapeutic features and emergency surgical strategy]. / Emorragia digestiva da tumore neuroendocrino del duodeno. Aspetti diagnostico-terapeutici e strategia chirurgica in emergenza.

The Authors report a rare case of duodenal neoplasia in a 17 year old boy. The patient was admitted in an emergency setting for hemorrhagic shock and duodenal perforation. Laparotomy was performed and a huge perforated neoplasia of the duodenum was found. Conservative approach was preferred, since the intraoperative histology was unuseful in choosing the better procedure: thus just a tumorectomy and closure of the duodenum were performed. Pathology examination demonstrated a neuroendocrine primitive duodenal tumors not well differentiated and with high grade of malignancy. The Authors discuss the role of the elements, clinical features and pathology, as well as emergency and postoperative management.

Rapid modification of aggressiveness of a primary non-Hodgkin lymphoma of uterine cervix.

Primary malignant lymphoma of the uterine cervix is an extremely rare condition, with only about 100 cases reported in international literature. The diagnosis can be difficult, as stated by some authors finding only 10 up to 40% of cases of cervical lymphoma diagnosed by positive cytology. We present a case of primary malignant lymphoma of the cervix in a 57 year old woman treated at the Department of Gynecological Oncology at the Regina Elena Cancer Institute in Rome, with a sudden and unfavorable outcome.

[Pica and intestinal occlusion: a clinical case]. / Pica ed occlusione intestinale: caso clinico.

Accidental or voluntary foreign bodies ingestion is a frequent reported event in emergency departments. Complication, foreign body shape related are not often observed and, once occurred, just few a cases need an open surgery approach, about 1%. The Authors report the case of a young woman with pica admitted to their Department in an emergency setting for acute intestinal obstruction due to the ingestion of not specified amount of elastics, which required an open surgery operation.

[Pneumatosis cystoides intestinalis in emergencies: clinical management and treatment. 2 case reports]. / La pneumatosi cistica intestinale in urgenza: gestione e trattamento dei pazienti. Due casi clinici.

Pneumatosis Cystoides Intestinalis gives many diagnostic and therapeutic troubles especially when it occurs in patient admitted in an emergency setting. The Authors report two cases of PCI related to patients admitted into the Emergency Department (DEA II) with diagnosis of intestinal perforation, mode according to the radiological findings of free subfrenic air, but not confirmed at physical examination. The Authors discuss the role that imaging and physical examination play in evaluating this kind of patients, considering the etiopathogenetic hypothesis about this rare disorder.

[Emergency treatment and diagnosis of appendix mucocele]. / Considerazioni su trattamento e diagnosi in urgenza di mucocele appendicolare.

The Authors report a case of appendicular mucocele admitted in an emergency setting in the Emergency Department (DEA II). The patient, 78 y-old man, went to attention complaining diffuse abdominal pain: physical examination revealed mild tenderness and right lower quadrant pain to palpation. Rx plain and CT scan demonstrated a right iliac fossa cystic lesion with mural calcification, adherent to the caecum. On basis of imaging, clinical and laboratory findings the patient underwent surgery postoperative diagnosis was mucocele of the appendix. The aim of this report is to discuss the role of imaging and clinical approach in treatment of appendicular mucocele, which is known to be so aspecific in presentation, especially when it occurs in an emergency setting.

[Compartment syndrome or gas gangrene? A case report]. / Sindrome compartimentale o gangrena gassosa? Caso clinico.

A case of forearm compartment syndrome due to a minor trauma is reported. The severe clinical conditions due to a shock state lead to an initial misdiagnosis of clostridial myonecrosis. The patient, 68 y-old woman, was admitted to the intensive care unit of Authors' hospital for a traumatic injury of the right forearm. A diagnosis of gas gangrene due to clostridial myonecrosis was done and forearm amputation suggested. In spite of this indication a decompression fasciotomy of the forearm compartments was performed as well as a hyperbaric oxygene therapy. Since culture of necrotic tissue samples did not demonstrate any bacterial growth, the Authors decided to avoid amputation and perform a radial arteriovenous fistula to improve venous return and reduce distal edema and continuous bleeding, with a complete recovery within 40 days. Good evaluation of patient with suspected compartment syndrome means correct and not delayed treatment, avoiding invalidating outcome.

[Guidelines for routine assessment of cardiologic surgical risk: electrocardiogram]. / Linee guida per la valutazione routinaria del rischio chirurgico cardiologico: l'elettrocardiogramma.

Cardiac complications are the main cause of perioperative mortality. A preoperative electrocardiogram and cardiologist's consultation are usually performed to get information about cardiac state of patients undergoing surgery and to prevent complications. In their study the Authors applied to 1715 patients undergoing surgery an evaluation schedule for the cardiac surgical risk, including an ECG as first-level test, performed systematically on the whole sample. The aim was to assess predictive value of this preoperative examination to verify its efficacy as routine test. Basing on results achieved, electrocardiogram is not routinely indicated before noncardiac elective surgery, but it should be requested for the patients having high risk of cardiac complications at an accurate clinical-anamnestic examination. Therefore, clinical judgement, that is the first level of any preoperative evaluation, should be the basis for ordering an ECG to be considered a second-level test.

Influence of body mass on glycemic control in a type 2 diabetic population: a 3-year follow-up.

Obesity is often associated with type 2 (non insulin-dependent) diabetes. A growing body of evidence support the hypothesis that these two diseases share a common pathogenesis. Nevertheless, experience derived from clinical observation on type 2 diabetic patients indicates that reduction of body weight is not always accompanied by an improvement in metabolic control and that a good metabolic control is often obtained without influencing body composition. Aim of the present study was to evaluate the relationship between body mass and glycemic control in a type 2 diabetic population by a 3 years observational study. A cohort of 562 subjects was studied. At entry more than 80% of patients were overweight or obese according to the body mass index (BMI) scale and this proportion was not significantly reduced at the end of the follow-up. At entry all patients had a glycosylated hemoglobin (HbA1c) value above 8.1% whereas at the end of follow-up more than 2/3 of patients were in good metabolic control. No relationship was observed between modification of body mass and metabolic control. These data confirm the high frequency of obesity among type 2 diabetic individuals but they suggest that impaired glucose metabolism and alteration of body weight have different pathogenesis.

Coronary heart disease, type 2 diabetes mellitus and cardiovascular disease risk factors: a study on a middle-aged and elderly population.

The risk for all the manifestations of atherosclerotic disease is increased in patients affected by type 2 diabetes mellitus. The aim of the present work was to evaluate the prevalence of coronary heart disease (CHD) in a well-characterized middle-aged and elderly Italian diabetic population. The population studied included 3862 subjects, i.e. all the patients affected by type 2 diabetes of age >or=50 years attending the outpatient diabetes care unit of INRCA in Ancona (Italy) from 1 August 1997 to 31 July 1998. We collected and analysed both clinical and laboratory data by means of a computerized data base for the outpatient clinic management. The prevalence rate of CHD was 20.25% in this population. The groups with CHD and without CHD did not differ significantly with respect to age at onset of diabetes, body mass index and HbA1c levels, while patients with CHD were significantly older than patients without CHD and had a longer duration of diabetes. The prevalence of patients with hypertension (52.9 vs 63.0%, P<0.001), hypercholesterolemia (11.6 vs 14.1%, P<0.05) and hyperlipidemia (17.8 vs 23.3%, P<0.001) was significantly higher in the group of diabetic subjects affected by CHD than in patients not affected by heart ischemic disease. It might be hypothesized that the improvement of metabolic profile and the currently feasible control of non-diabetic risk factors could reduce cardiovascular disease rates in type 2 diabetic patients.

Synthesis and aldose reductase inhibitory activity of new N-(benzyloxy) glycine derivatives.

This paper reports the synthesis and aldose reductase (AR) inhibitory properties of some N-(benzyloxy) glycine derivatives (compounds 2-6), structurally related to the previously described N-(aroyl)-N-(arylmethyloxy) glycines A which had proved to possess an appreciable AR inhibitory activity. In compounds 2-5, spacers of different lengths and degrees of rigidity were inserted between the phenyl ring and the carbonyl group of type A derivatives; compound 6 differs from the most active type A derivative (compound 1) in the replacement of the methoxy moiety in the para position of the benzoyl side-chain with a group with different electronic characteristics, such as the trifluoromethyl moiety. Biological results indicated that among compounds 2-5 only derivative 3, which presents a CH2CH2 spacer between the phenyl and the carbonyl moiety, proved the possess AR inhibitory properties analogous to those of 1, while all the other compounds proved to be devoid of any significant activity. Furthermore, compound 6 showed an inhibitory activity about 3 times lower than that of 1.