C-reactive protein but not procalcitonin may predict antibiotic response and outcome in infections following major abdominal surgery.

We aimed to evaluate the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) as markers of infection, sepsis and as predictors of antibiotic response after non-emergency major abdominal surgery. We enrolled, from June 2015 to June 2019, all patients who underwent surgery due to abdominal infection (peritoneal abscess, peritonitis) or having sepsis episode after surgical procedures (i.e. hepatectomy, bowel perforation, pancreaticoduodenectomy (PD), segmental resection of the duodenum (SRD) or biliary reconstruction in a Tertiary Care Hospital. Serum CRP (cut-off value < 5 mg/L) and PCT (cut-off value < 0.1mcg/L) were measured in the day when fever was present or within 24 h after abdominal surgery. Both markers were assessed every 48 h to follow-up antibiotic response and disease evolution up to disease resolution. We enrolled a total of 260 patients underwent non-emergency major abdominal surgery and being infected or developing infection after surgical procedure with one or more microbes (55% mixed Gram-negative infection including Klebsiella KPC, 35% Gram-positive infection, 10% with Candida infection), 58% of patients had ICU admission for at least 96 h, 42% of patients had fast track ICU (48 h). In our group of patients, we found that PCT had a trend to increase after surgical procedure; particularly, those undergoing liver surgery had higher PCT than those underwent different abdominal surgery (U Mann-Whitney p < 0.05). CRP rapidly increase after surgery in those developing infection and showed a statistical significant decrease within 48 h in those subject being responsive to antibiotic treatment and having a clinical response within 10 days independently form the pathogens (bacterial or fungal). Further we found that those having CRP higher than 250 mg/L had a reduced percentage of success treatment at 10 days compared to those < 250 mg/mL (U Mann-Whitney p < 0.05). PCT did not show any variation according to treatment response. CRP in our cohort seems to be a useful marker to predict antibiotic response in those undergoing non-emergency abdominal surgery, while PCT seem to be increased in those having major liver surgery, probably due to hepatic production of cytokines.

Different anal pressure profiles in patients with anal fissure.

BACKGROUND: A consistent debate exists about the association between anal fissure and hypertonic anal canal. The aim of this study was to determine if the manometric findings in patients with chronic anal fissures varied according to the topography of the fissure. PATIENTS AND METHODS: Seventy-three outpatients (52 men, 71%) with chronic anal fissures and nine healthy volunteers (5 men, 55%) were examined. Patients were classified according to the topography of the anal fissures: posterior midline (group A), anterior midline (group B), and lateral position (group C). We use computerized anorectal manometry to evaluate anal resting pressure, maximal voluntary contraction, recto-anal inhibitory reflex, rectal sensations and rectum compliance. RESULTS: In Group A, the mean pressure was higher than that of controls (p<0.05), and the resting pressure 2 cm from anal verge was higher than that of other groups and controls (p<0.05). Normotonic anal canal was found in 49.1% of patients in group A, in 66% of those in group B and in 57.1% of those in group C. Four elderly patients (7%) of group A had a hypotonic anal canal. No differences were found regarding maximal voluntary contraction, recto-anal inhibitory reflex, rectal sensations and rectum compliance between patients and controls. CONCLUSIONS: Patients with chronic anal fissures may have several anal pressure profiles. The anal canal is often normotonic. Fissures with hypertonic or normo-hypotonic anal canal need different therapies.

[Solid pseudopapillary tumour of the pancreas. Report of a case]. / Il tumore solido pseudopapillare del pancreas. Presentazione di un caso clinico.

Solid pseudopapillary pancreatic tumour is an uncommon disease including 2.7% of exocrine malignancies of the pancreas. Its low incidence is associated with an uncertain prognosis and with difficult diagnostic and therapeutic problems, despite routine use of ultrasonography, TC and RMN. A case of solid pseudopapillary pancreatic tumour in a young woman is reported: the clinicopathologic features, diagnostic imaging and surgical treatment are discussed. Surgery is the primary option. Prognosis is however not fully known. From a review of the literature it is suggested that these tumours should be regarded as potentially malignant.

Detection of Mirizzi syndrome with magnetic resonance cholangiopancreatography: laparoscopic or open approach?

Imaging of the gallbladder and biliary tract has changed dramatically in the past 20 years. Magnetic resonancecholangiopancreatography provides a noninvasive alternative to endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography in the diagnosis of Mirizzi syndrome. In this laparoscopic era, when diagnosis is certain, surgeons must choose between a laparoscopic and a traditional open approach. The authors review their cases of hepatobiliary surgery during the period 1993-2000. Three cases of Mirizzi syndrome (0.4%) were observed among 712 surgical hepatobiliary patients (two type 1 cases and one type 2 case). The authors suggest that with Mirizzi syndrome type 1, laparoscopy together with peroperative cholangiography should be used to resolve anatomic doubts. If clipping of the cystic duct is possible and certain, then laparoscopy may be continued and finished. In the case of cholecystocholedochal fistula (Mirizzi syndrome type 2), when the diagnosis is determined before surgery, the authors believe that laparoscopy is dangerous. Adhesions, inflammation, and anatomy changes may cause injuries to the main bile duct, so an open traditional approach is suggested.

[Surgical complications following pancreaticoduodenectomy: results of a single center experience]. / Le complicanze chirurgiche post-duodenocefalopancreasectomia: risultati di una esperienza monocentrica.

Pancreaticoduodenectomy represents the only therapeutic option for cefalo-pancreatic and periampullary cancers. Surgical and anaesthesiological techniques development over the last twenty years has granted an operative mortality decrease. However, surgical morbidity is still high, with an incidence of 30-50%. A 20 year experience of a single Centre is examined retrospectively: 121 patients underwent pancreatic resection with radical intent. Type of operation or re-operation, operative mortality within 30 days, general and surgical morbidity, postoperative hospital stay were analysed. Average recovery time was 24 days (range 12-65); operative mortality was 5.8% (7/121); general morbidity, including medical and surgical complications, was observed in 47 patients (38.8%). Pancreatic fistula occurred in 16 patients (13.2%); ten of these underwent a second operation. Patients who underwent pancreaticoduodenctomy were divided as follows: 76 pts. received a pylours-preserving pancreaticoduodenectomy and 45 a Whipple's resection. Neither surgical complications incidence nor mortality rate were significantly different between the two groups. Postoperative complications following pancreaticoduodenectomy are still frequent and severe. In particular, pancreatic fistula represents the most relevant complication following pancreaticoduodenectomy. The Authors suggest that standard and meticulous surgical procedures together with continued efforts to improve postoperative follow-up, support early detection of complications and improvement of results in most patients.

[Central segmental pancreatectomy in benign and borderline neoplasms of the pancreatic isthmus and body]. / La pancreasectomia segmentaria centrale nelle neoplasie benigne e borderline dell'istmo e del corpo del pancreas.

We report our experience with middle segment pancreatectomy for benign, cystic and borderline tumours of the neck and body of the pancreas. The guidelines for management of these tumours are unclear. Formerly they were usually resected with a pancreatico-duodenectomy or distal pancreatectomy including the spleen. However, such operations may cause high morbidity, a notable wastage of normal tissue and an unnecessary risk of diabetes mellitus and splenic loss. Four patients (age range: 34-72 years) with tumours of the neck or body of the pancreas underwent a middle segmental pancreatectomy. The cephalic stump was sutured with duct ligation. The distal stump was anastomosed with a Roux-en-Y jejunal loop. Neither pancreatic fistulas nor operative death occurred in any of the patients. In 3 patients with serous cystadenoma and in one with mucinous cystadenoma, the tumours measured 3.5 to 7 cm in size. These were located in the neck and body of the pancreas and could not be safely enucleated without compromising the pancreatic duct. All tumours were resected with clear margins. The mean operative time was 230 minutes and the median postoperative hospital stay 14 days (range: 10-23 days). The patients have been followed up for five years after surgery and all are disease-free. None of the patients became diabetic or presented exocrine insufficiency. Middle segment pancreatectomy may be an appropriate technique for selected benign or borderline pancreatic tumours in the neck and body of the pancreas. This procedure has an acceptable surgical risk when compared to that of major pancreatic resections and preserves pancreatic function and the spleen.

Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine.

PURPOSE: This study was performed according to a prospective, randomized, open design. The aim was to test the efficacy of local application of nifedipine ointment in healing acute thrombosed external hemorrhoids. METHODS: Ninety-eight patients who gave their informed consent were recruited; they received clinical examination and anoscopy. A questionnaire to evaluate symptoms, pain, and concurrent use of analgesics was administered. Patients treated with nifedipine (n = 50) used topical 0.3 percent nifedipine and 1.5 percent lidocaine ointment every 12 hours for two weeks. The control group, consisting of 48 patients, received topical 1.5 percent lidocaine ointment during therapy. RESULTS: Results obtained were as follows: complete relief of pain in 43 patients (86 percent) of the nifedipine-treated group as opposed to 24 patients (50 percent) of the control group after 7 days of therapy (P < 0.01); oral analgesics were used by 4 patients (8 percent) in the nifedipine-treated group as opposed to 26 patients (54.1 percent) of the control group after 7 days of therapy (P < 0.01); and resolution of acute thrombosed external hemorrhoids was achieved after 14 days of therapy in 46 patients (92 percent) of the nifedipine-treated group, as opposed to 22 patients (45.8 percent) of the control group (P < 0.01). We did not observe any systemic side effect in patients treated with nifedipine. CONCLUSIONS: Our study clearly demonstrates that the use of topical nifedipine, which at present is for treatment of cardiovascular disorders, is a reliable new option in the conservative treatment of thrombosed external hemorrhoids.

[Primary ano-rectal melanoma]. / Il melanoma primitivo ano-rettale.

Primary malignant anorectal melanoma is an uncommon disease that accounts for 1% of anorectal malignancies. Its virulent malignancy is associated with a poor prognosis and with difficult diagnostic and therapeutic problems. The operative management of these patients is controversial. Clinicopathologic features and surgical treatment of 6 patients with primary anorectal melanoma were studied retrospectively. There was a male preponderance (2:1) with a mean age of 62 years (range: 34-74). The site of origin of the melanoma was rectal in one patient and in the anorectal junction in five patients. Atypical intramucosal melanocyte proliferation was associated with rectal melanoma. The maximum tumor size from 2 to 5.5 cm. Common initial symptoms were rectal bleeding and/or tenesmus. CT was useful for tumor staging. Two patients had distant metastases at initial presentation. Four patients underwent "curative" treatments by abdominoperineal resection and 2 by local excision. The survival for the group as a whole was poor (mean: 12.6 months; range: 7-30 months). Surgery is the primary option. The prognosis, however, is poor, since metastatic disease is commonly established at presentation. Atypical intramucosal melanocyte proliferation may be a marker in association with tumor sited in the rectum.

Nifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study.

PURPOSE: This study was performed according to a prospective, randomized, double-blind, multicenter design. The aim was to test the efficacy of local application of nifedipine gel" in healing acute anal fissure by relaxing the internal anal sphincter. METHODS: Two hundred eighty-three patients who gave informed consent were recruited; they received a clinical examination. A questionnaire to evaluate the symptoms and the pain was administered, and a proctoscopy and anorectal manometry were performed. Patients treated with nifedipine (n = 141) used topical 0.2 percent nifedipine gel every 12 hours for three weeks. The control group, consisting of 142 patients, received topical 1 percent lidocaine and 1 percent hydrocortisone acetate gel during therapy. Manometry was performed before and on Days 14 and 21. Anal pressures were measured by recording resting and squeeze pressures. RESULTS: Results obtained were as follows: total remission from acute anal fissure was achieved after 21 days of therapy in 95 percent of the nifedipine-treated patients (P < 0.01), as opposed to 50 percent of the controls (P < 0.01), and previously elevated maximum resting anal pressures decreased from a mean value +/- standard deviation of 72.5 +/- 10.07 mmHg to 50.5 +/- 10.03 mmHg in the nifedipine group. This represents a mean reduction of 30 percent (P < 0.01). We also observed a significant decrease in squeeze pressures in nifedipine-treated patients (from a mean +/- standard deviation of 130.5 +/- 19.25 mmHg to 108.5 +/- 18.55 mmHg, a mean reduction of 16.8 percent; P < 0.01). No changes in anal pressures were observed in the control group. We did not observe any systemic side effect or significant anorectal bleeding in patients treated with nifedipine. CONCLUSIONS: Our study clearly demonstrates that the therapeutic use of nifedipine, which at present is used only in cardiovascular pathologies, should be extended with local use to the conservative treatment of anal fissures.

[Carcinoma of the cervical esophagus. Problems of surgical technique]. / Carcinoma dell'esofago cervicale. Problemi di technica chirurgica.

The tape shows the surgical technique used by the Authors for the alimentary tract reconstruction after total esophagectomy for cancer of the upper esophagus. A review of the main reconstructive techniques used for this disease is reported.