Acute appendicitis. Update of clinical scores.

OBJECTIVES: Evaluate Alvarado Score's (AS) accuracy related with C-reactive protein (CRP). Evaluate the accuracy rate of ultrasonography (US). MATERIALS AND METHODS: We analyzed data on 290 patients admitted to Emergency Department (ED) of Sant'Andrea Hospital (Rome - Italy) presenting abdominal pain in lower quadrants between Jan2009-Apr2015. AS, laboratory tests, images and report from CT-scan and US were collected. Histological examination is considered as Gold Standard. We calculated Specificity(Sp), Sensitivity(Se), Accuracy(Ac), positive predictive value(PPV), and negative predictive value(NPV). We use Exact Fisher Test (EFT) for samples less than 50 units, and Chi square test (χ2). CRP were assessed as possible laboratory marker to be added to AS. RESULTS: Two hundred and forty patients (82%) were enrolled following the inclusion criteria. The variations obtained from the AS with C-reactive protein show no difference. CT-scan vs US results show a higher Sp for US despite CT (p= 0.0509 χ2=3.803. Se and NPV are higher in CT compared to the US (Se: p=0.000315 χ2= 12.88 NVP: p=0.015. We evaluated Ac of US and CT within the individual groups (low(L), Intermediate(I), High(H): L; 37 patients show no statistically significant difference (EFT=1; p>0.05). I: show superiority of CT-scan in Se and NPV (FE:0.0162 p<0.05; FE:0.0432 p<0.05). Regarding H only Se show an acceptable p-value (p<0.0021). CONCLUSION: Alvarado score (AS) can be used as the first diagnostic approach in the diagnosis of acute appendicitis (AA). Ultrasound must be considered the first level instrumental examination; necessary and sufficient in low risk patients (0-3 pt) to exclude, with a high reliability rate, the diagnosis of acute appendicitis. KEY WORDS: Acute Appendicitis, Alvarado Score, CT scan, Ultrasound, Peritonitis.

Reconstruction After Distal Gastrectomy for Gastric Cancer: Billroth 2 or Roux-En-Y Procedure?

BACKGROUND/AIM: Distal gastrectomy (DG) represents the only curative treatment for most mid-lower gastric cancers (GCs). As of 2017, however, no reconstructive modality to conduct after DG has gained unanimous consensus. Additionally, most authors have investigated Billroth 1 and Roux-en-Y (RY) rather than Billroth 2 (B2) reconstruction. We analyzed B2 and RY gastrojejunostomy to identify the preferable technique and augment the available information on B2 restoration. PATIENTS AND METHODS: We retrospectively selected 132 GC patients who were consecutively submitted to DG at our institution between April 2005 and February 2016. B2 and RY anastomosis were accomplished as methods of reconstruction (respectively 36 and 96 cases). We compared these techniques in terms of clinicopathological, surgical, postoperative and oncologic outcomes. RESULTS: Compared to RY gastrojejunostomy, B2 reconstruction was significantly associated with a greater mean number of harvested lymph nodes (26.03 vs. 21.65, p=0.045) but also with a longer hospital stay (22.8 vs. 15.7 days) (p=0.022) and higher readmission rate (28.57% vs. 3.1%, p<0.0001). On multivariate analysis, reconstruction method was the most significant independent prognostic factor for hospital readmission. CONCLUSION: In light of our results, we propose that B2 gastrojejunostomy deserves more study in order to better identify the best post-DG anastomosis.

Procalcitonin Reveals Early Dehiscence in Colorectal Surgery: The PREDICS Study.

OBJECTIVES: We designed a multicentric, observational study to test if Procalcitonin (PCT) might be an early and reliable marker of anastomotic leak (AL) after colorectal surgery (ClinicalTrials.govIdentifier:NCT01817647). BACKGROUND: Procalcitonin is a biomarker used to monitor bacterial infections and guide antibiotic therapy. Anastomotic leak after colorectal surgery is a severe complication associated with relevant short and long-term sequelae. METHODS: Between January 2013 and September 2014, 504 patients underwent colorectal surgery, for malignant colorectal diseases, in elective setting. White blood count (WBC), C-reactive protein (CRP) and PCT levels were measured in 3rd and 5th postoperative day (POD). AL and all postoperative complications were recorded. RESULTS: We registered 28 (5.6%) anastomotic leaks. Specificity and negative predictive value for AL with PCT less than 2.7 and 2.3 ng/mL were, respectively, 91.7% and 96.9% in 3rd POD and 93% and 98.3% in 5th POD. Receiver operating characteristic curve for biomarkers shows that in 3rd POD, PCT and CRP have similar area under the curve (AUC) (0.775 vs 0.772), both better than WBC (0.601); in 5th POD, PCT has a better AUC than CRP and WBC (0.862 vs 0.806 vs 0.611). Measuring together PCT and CRP significantly improves AL diagnosis in 5th POD (AUC: 0.901). CONCLUSIONS: PCT and CRP demonstrated to have a good negative predictive value for AL, both in 3rd and in 5th POD. Low levels of PCT, together with low CRP values, seem to be early and reliable markers of AL after colorectal surgery. These biomarkers might be safely added as additional criteria of discharge protocols after colorectal surgery.

Laparoscopic versus robotic-assisted colectomy and rectal resection: a systematic review and meta-analysis.

PURPOSE: Lately, the main technical innovations in the field of colorectal surgery have been the introduction of laparoscopic and robotic techniques; the aim of this study is to investigate the results and the advantages of these two surgical approaches. METHODS: Twenty-two studies including 1652 laparoscopic and 1120 robotic-assisted resections were analyzed and categorized into right, left, and pelvic resections of the middle/low rectum, aiming to the following outcomes: operating time, blood loss, bowel function recovery, return to oral intake, morbidity, hospital stay, and costs. RESULTS: The vast majority of the studies were non-randomized investigations (19/22 studies) enrolling small cohorts of patients (median 55.0 laparoscopic and 34.5 robotic-assisted group) with a mean age of 62.2-61.0 years. Funnel plot analysis documented heterogeneity in studies which combined cancers and benign diseases. Our meta-analysis demonstrated a significant difference in favor of laparoscopic procedures regarding costs and operating time (standardized mean difference (SMD) 0.686 and 0.493) and in favor of robotic surgery concerning morbidity rate (odds ratio (OR) 0.763), although no benefits were documented when analyzing exclusively randomized trials. When we differentiated approaches by side of resections, a significant difference was found in favor of the laparoscopic group when analyzing operating time in left-sided and pelvic procedures (SMD 0.609 and 0.529) and blood loss in pelvic resections (SMD 0.339). CONCLUSION: Laparoscopic techniques were documented as the shorter procedures, which provided lower blood loss in pelvic resections, while morbidity rate was more favorable in robotic surgery. However, these results could not be confirmed when we focused the analysis on randomized trials only.

Gastrointestinal stromal tumors associated with neurofibromatosis 1: a single centre experience and systematic review of the literature including 252 cases.

AIMS: The objectives of this study were (a) to report our experience regarding the association between neurofibromatosis type 1 (NF1) and gastrointestinal stromal tumors (GISTs); (b) to provide a systematic review of the literature in this field; and (c) to compare the features of NF1-associated GISTs with those reported in sporadic GISTs. METHODS: We reported two cases of NF1-associated GISTs. Moreover we reviewed 23 case reports/series including 252 GISTs detected in 126 NF1 patients; the data obtained from different studies were analyzed and compared to those of the sporadic GISTs undergone surgical treatment at our centre. RESULTS: NF1 patients presenting with GISTs had a homogeneous M/F ratio with a mean age of 52.8 years. NF1-associated GISTs were often reported as multiple tumors, mainly incidental, localized at the jejunum, with a mean diameter of 3.8 cm, a mean mitotic count of 3.0/50 HPF, and KIT/PDGFR α wild type. We reported a statistical difference comparing the age and the symptoms at presentation, the tumors' diameters and localizations, and the risk criteria of the NF1-associated GISTs comparing to those documented in sporadic GISTs. CONCLUSIONS: NF1-associated GISTs seem to have a distinct phenotype, specifically younger age, distal localization, small diameter, and absence of KIT/PDGRF α mutations.

[Experimental teaching program on cooperation between "Sapienza" University of Rome and the University Hospital "Le Bon Samaritain" in N'Djamena, Chad]. / Progetto di sperimentazione didattica tra Sapienza - Università di Roma e l'Ospedale Universitario Le Bon Samaritain di N'Djamena, Ciad.

BACKGROUND: The shortage of essential surgical care in sub-Saharan Africa is a worldwide problem. Lack of healthcare workers, surgeons and very limited resources are the reason for this critical health crisis. Furthermore in Africa many physicians as soon as they get a degree emigrate in more attractive countries. METHODS: "Multidisciplinary teaching support to a new Faculty of Medicine in N'Djamena - Chad" is a teaching cooperation program between «Sapienza¼ University of Rome and the University Hospital "Le Bon Samaritain" in N'Djamena, Chad. The project started in 2010, with the aim of cooperating in teaching medical students of African origin and in training Italian residents in sub-Saharan surgical and internal pathologies. In Chad the greatest surgical burden (about 11% of the total global diseases) is created by injuries, cancers, congenital anomalies, appendicitis, bowel obstructions, hernias, abscesses (by amebiasis or others) and obstetric emergencies. CONCLUSIONS: Up till now healthcare in Africa especially in rural areas has been provided by international organisations,we believe that academic collaborations between high-income and low-income Nations is necessary to meet the real needs of the african surgical workforce; at the same time it is very useful for store of knowledge of our residents.

[Gastric pacing to treat morbid obesity: two years experience in four patients]. / Il gastric pacing per il trattamento dell'obesità patologica. Esperienza a due anni in 4 pazienti.

BACKGROUND: Gastric pacing to treat morbid obesity has been found to be safe and the implant technique simple to perform. Appetite is reduced and satiety is increased after the implant. There are two components in the Implantable Gastric Stimulation (IGS): (a) an electrical stimulator connected to a (b) bipolar lead that is positioned in the muscle wall of the stomach. We describe the optimal procedure to safely place the components. We present our results after preliminary experiences. METHODS: From August 2005 to January 2006, 4 patients (F) mean age 44 (33-63) underwent to IGS implant. The mean BMI was 41.8 (378-47), mean weight 117.2 Kg (107-133) . The IGS was activated 30 days after implant. Fasting and postprandial plasma ghrelin concentrations after a test meal were measured before and 1, 2, 3 and 6 months after implanting operation. RESULTS: All procedures were successfully completed laparoscopically. There were no major operative complications. Postoperative course was uneventful in all cases. One patient was lost to follow up after six months. Postoperative lead dislodgement and cutaneous decubitus occurred in another patient, making necessary the removing of the device. For the other two patient only in one there was a significant weight loss (49 Kg), in the second weight was unchanged. Plasma ghrelin concentrations were no correlated among patients, and results were not in line with what waited by the producer. CONCLUSION: Morbid obese patients can undergo IGS implantation by laparoscopy with minimal perioperative complications. Attention to technical details is essential. In accordance with the producer (Medtronic) our data demonstrate that gastric pacing is a safe procedure for selected patients supported by adequate psychological treatment, but outcome about weight loss should be evaluated among bigger trial, as our experience didn't give satisfactory results, and therefore discouraged us to carry on with the study.

Multiple giant diverticula of the foregut causing upper gastrointestinal obstruction.

Small bowel diverticulosis represents an uncommon disorder (except for Meckel diverticulum) often misdiagnosed since it causes non-specific gastrointestinal symptoms. Most of times the diagnosis is carried out in case of related complications, such as diverticulitis, hemorrhage, perforation or obstruction. Intestinal obstruction can be caused by inflammatory stenosis due to repeated episodes of diverticulitis, volvulus, intussusception or jejunal stones. Herein we report a case of multiple jejunal diverticula causing chronic gastrointestinal obstruction.

A large porocarcinoma of perineal region: MR findings and review of the literature.

We present the case of a 54-year-old woman affected by a large perineal region eccrine porocarcinoma, with a wide local invasion. We discuss the clinical presentation and the imaging findings and review the literature.

Neurectomy to prevent persistent pain after inguinal herniorraphy: a prospective study using objective criteria to assess pain.

BACKGROUND: Although tension-free mesh repair has markedly improved the outcome of inguinal hernia surgery, it has only minimally reduced the incidence of persistent postoperative pain. The pathogenesis of this complication and treatment remain unclear. STUDY DESIGN: In order to objectively assess whether iliohypogastric neurectomy reduces the incidence and intensity of persistent postoperative pain, we prospectively studied 100 male patients with bilateral inguinal hernia who underwent tension-free surgical repair, combined with iliohypogastric neurectomy on the right side alone. Pain was evaluated postoperatively on days 1 and 7 and at 1 and 2 years by means of a visual analog scale. Patients were given a questionnaire including coded terms for describing pain. These terms were designed to compare pain on the neurectomized and non-neurectomized sides and assess altered sensation (hypoesthesia and paresthesia) on both sides. RESULTS: There were differences in the incidence and intensity of pain between the neurectomized and non-neurectomized sides, though these differences were not significant. Individual patient assessment showed that from postoperative day 7 onward patients had on average less pain on the neurectomized side. Pain reduction was more prominent in patients who scored 4 or more on the visual analog scale. No significant difference was found in the incidence of sensory alterations between the two sides. Two years after inguinal hernia repair, only one of the 100 patients studied still had persistent pain (>4 on the visual analog scale); this pain was on the non-neurectomized side. CONCLUSIONS: Our prospective data do not reach statistical significance to claim that iliohypogastric neurectomy reduces the incidence and intensity of persistent postoperative pain after tension-free inguinal hernioplasty. Studies on larger patient samples are warranted to provide definitive, statistically supported conclusions.

Splenic infarction, rare cause of acute abdomen, only seldom requires splenectomy. Case report and literature review.

Splenic infarction is a rare disorder, commonly without a characteristic symptomatology, that rarely requires surgical procedure; in fact it has the peculiar feature of an high tendency for complete healing after the only medical approach. Furthermore in order to prevent OPSI, only in case of clear, persistent symptoms or complications it may be necessary surgical laparoscopic or open approach. The Authors report on a recent case observed in emergency of splenic infarction with infectious complications that made the surgical procedure mandatory.

[Congenital intestinal malformations: clinical evaluation and specific treatment. Case report and literature review]. / Le malformazioni intestinali congenite: inquadramento clinico e trattamento delle complicanze. Caso clinico e revisione della letteratura.

A case of acute abdomen due to diastasic perforation of the right colon by volvulus on mesenterium commune with associated agenesis of the left kidney and urogenital malformations in a young woman is reported. The case emphasizes the complexity and the polymorphism of congenital abdominal malformations, particularly predisposing to volvulus, that can represent a really challenge for emergency surgeon. The A.A. analyze literature about congenital intestinal anomalies to evaluate clinical, diagnostic and therapeutical problems, and they remark features to take into consideration in emergency: clinical history in non-operated patient of abdominal pain and biliary vomit with spontaneous resolutions; nutritional compromise; hypothetical diagnosis of anorexia or food intolerance; malformations in other organs or systems and, one mostly, young age. The correct interpretation of these symptoms can suggest suspicious of an occlusive complication due to intestinal malformations. Radiological data and the exploratory laparotomy or laparoscopy will confirm our intuition. If otherwise diagnosis of the cause underlying the chronic recurrent abdominal pain are delayed, surgical operation in emergency condition will be more aggressive and anatomical structures sacrificed.

[The surgical treatment of neoplastic colorectal occlusions]. / Il trattamento chirurgico delle occlusioni neoplastiche colo-rettali.

The emergency treatment for neoplastic occlusions of rectum still needs debugging. While we finds perfect accord in to directly treat with a right hemicolectomy (more or less widened) the tumours from cecum to the first portion of the right colon, not the indications are likewise shared in presence of neoplastic stenosis of sigma-rectum. The treatment of urgency of these tumours is lent to so many variable and the tendencies too are constantly in evolution in relationship to the improvement of the technologies and the surgical devices. We have to chose from the two-three times intervention (now with less succession), or the total or subtotal colectomy otherwise the most used left hemicolectomy and anterior resection for sigmoid colon. Presenting our historical cases of 31 years of activity (Institute of Surgical Emergency Department--University La Sapienza of Rome), 564 neoplastic occlusions of the colon (75.7% sigma-rectum), the Authors describe their attitude both of approach and of surgical therapy in urgency that has brought them to practise in the 65.6% of the cases the anterior resection without protection colostomy, with extraperitoneal anastomosis and reconstitution of the pelvic peritoneum, in all the stenosis under descendant--sigma. In the last period it is frequent more and more the tendency to the positioning of a stent on the neoplastic stenosis: this treatment allows us to overcome the emergency to operate then under fitter conditions.