Diagnostic, therapeutic and health-care management protocol for major abdominal trauma at the "Santa Maria" Hospital of Terni. Analysis of the results after two years.

BACKGROUND: Trauma is the fourth leading cause of death and is more common in people under 45 age. Abdominal trauma is cause of death in 7-10% of traumatized patients. Aim is to evaluate the effectiveness of the diagnostic, therapeutic and health-care management protocol for major abdominal trauma. METHODS: A prospective study called DGR Azienda Ospedaliera S. Maria Terni n. 159. was registered on February 2014. Patients with abdominal major trauma admitted at Santa Maria Hospital of Terni from January 2015 to December 2016 were considered in this paper. Patients' demographics, comorbidities, application of the operative and non operative management (OM-NOM), Mortality, effectiveness of diagnostics were investigated. RESULTS: The most of the patients were the elderly. Staff members were compliant and operated in conformity to the protocol for abdominal trauma. Non operative management (NOM) was performed in 63% of patients, according to data from the literature. On the other hand data with respect to the performing of diagnostic examinations as Focused assessment with ultrasonography for trauma (FAST), chest X-ray, Computed Tomography (CT) were discordant with literature. No patient underwent damage control surgery (DCS). Number of missed injuries (3.3%) and overall (13.3%), daily and weekend mortality were similar to those from the available literature. In our experience, the best results were found regarding the sensitivity of the FAST and CT in unstable and stable patients respectively, and the lower incidence of: NOM failure (NOM 0%, NOM plus endovascular treatment 14.4%) , mortality in stable patients (2.3%) and night mortality (5%). CONCLUSIONS: Despite the application of trauma protocol at Terni Hospital has been effective it can be further improved. KEY WORDS: Diagnostic, Emergency surgery, Major Abdominal Trauma, Therapeutic and health-care management protocol.

Urgency surgical treatment for duodenal GISTs: analysis of aged patients and review of the literature.

INTRODUCTION: Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms (85%) of the gastrointestinal (GI) tract; duodenal GISTs constitute 3-5% of all GISTs and represent 10-30% of all malignant tumours of the duodenum. Rarely, patients present severe bowel obstruction, perforation or severe bleeding. The radical resection with complete removal of the tumour remains the main therapeutic approach. We performed a local resection in patients with suspected GIST admitted for emergency treatment for GI bleeding. CASES: We present three cases of patients admitted for GI bleeding. The cause could be a GIST bleeding. In all cases, local resection was performed without a pancreaticoduodenectomy. Histological examination on surgical preparations showed that in two cases it was a GIST and in one case, it was a leiomyoma. DISCUSSION: Surgery remains the treatment of choice in the case of a GIST primitive without evidence of metastases, even for patients who are hospitalized for a bleeding emergency. Wide resections are not needed; it is important to remove completely the disease. In the case of duodenal GIST, it is important to get negative margins near the head of the pancreas, and this could take a PD. According to our experience and to the literature review, we believe that if the duodenal papilla or the periampullary region is not interested, you must perform a local resection. This is also because non-malignant tumours may present as GISTs and in these cases it is not recommended to run a PD. CONCLUSION: The treatment of choice for duodenal GISTs is complete surgical resection with negative resection margins. When the papilla or the periampullary region is involved we choose to perform pancreaticoduodenectomy; otherwise it is better to perform a local resection. In fact, local resection has lower morbidity and mortality, with a comparable outcome.

Surgery for colorectal cancer in elderly: a comparative analysis of risk factor in elective and urgency surgery.

INTRODUCTION: Colon cancer therapy is primarily surgical. Advanced age does not represent a contraindication to surgery. We analyse the results of surgery in ultra 75 patients undergoing surgery for colorectal cancer by examining the correlation between the comorbidity and any post-operative complications. MATERIALS AND METHODS: We surgically treated 66 patients for colorectal cancer, aged over 75. The examined subjects were compromised for various reasons. We have evaluated the different influences of risk factors in elective and urgency operation. DISCUSSION: Several studies have shown that age alone is not a significant prognostic factor in survival after colonic surgery. The assessment of general conditions in elderly patients, as demonstrated by the literature, is a fundamental moment in the management of colorectal cancer. CONCLUSIONS: The surgical choice should be made case by case (custom-made), not based on age only.

Is it safe and useful, laparoscopic peritoneal lavage in the treatment of acute diverticulitis of octogenarian patients? A multicenter retroprospective observational study.

BACKGROUND: Diverticular disease of the colon also affects older people. Generally, older patients with diverticulitis may be regarded as too risky to undergo surgery. This retroprospective multicentric observational study aims to assess the safety and benefits of laparoscopic peritoneal lavage (LPL) in elderly patients with perforated sigmoid diverticulitis. PATIENTS AND METHOD: We hospitalized in urgency 100 patients, aged over 75, for sigmoid diverticulitis. Sixty-nine patients were treated with conservative medical therapy, while 31 were treated surgically, in which the surgery was performed in urgency in 18 cases, while in election in 13 cases. Laparoscopic peritoneal lavage was made in urgency in five cases. RESULTS: The mean age of the sample was 81.72. Thirty-one patients underwent surgery, and five patients were treated in urgency with laparoscopic peritoneal lavage. Perioperative mortality was zero. None of the patients who underwent laparoscopic peritoneal lavage showed recurrent disease. CONCLUSION: Diagnostic laparoscopy can be useful in elderly patient, since these patients may benefit from a more conservative surgical strategy. The selection of patients to be subjected to laparoscopic lavage must be very rigorous.

Postoperative mortality and morbidity in older patients undergoing emergency right hemicolectomy for colon cancer.

INTRODUCTION: Even with the advances in surgical technique and perioperative care, morbidity and mortality after colorectal cancer surgery remain considerable, and patients (pt) who present as an emergency have an even higher mortality and morbidity rate. METHODS: A total of 35 pt with caecum or ascending colon cancer between January 2007 and June 2015, three departments in Italy and in Poland, were included in the study. The intention of surgery in all cases was curative resection with ileo-colic anastomosis. Comparative statistical analysis was performed. RESULTS: Acute bowel obstruction was the major complication of CRC that led to an emergency hemicolectomy. Postoperative mortality and morbidity rates were in total 12.5 and 28.1%, respectively. All the deaths happened in Poland. Of the pt, 42.8% had morbidity in Poland and 16.6% in Italy. Out of the pt, 25% presenting with perforation: 25% died, 25% had wound dehiscence, 12.5% had pulmonary oedema, and 12.5% had an intra-abdominal abscess. The mean age of the pt with complications in Poland and in Italy was 79.3 and 72.0 years, respectively. CONCLUSION: We observed that particularly lethal combination is older age, perforation with peritonitis and advanced stage of the cancer.

Cordylobia rodhaini infestation of the breast: Report of a case mimicking a breast abscess.

INTRODUCTION: Myiasis, parasitic infestation of the body by fly larvae, caused by the Cordylobia rodhaini is very rare with only fourteen cases published since 1970. We present a rare case of myiasis mimicking a breast abscess. PRESENTATION OF CASE: A 17-year-old female presented with a nodular ulcerative lesion in her left breast 14days following a trip to Ghana. She had been initially unsuccessfully treated with the antibiotic flucloxacillin following a misdiagnosis of a breast abscess. Following application of Vaseline to the breast wound, covering the wound for 2h and gentle manipulation the larvae was removed successfully and the patient made a good recovery. DISCUSSION: Presenting as an inflammatory papule with central opening oozing serosanguinous fluid myiasis secondary to C. rodhaini can easily be mistaken for a breast abscess, often avoiding detection by unsuspecting surgeons on initial assessment. In turn ineffective antibiotic treatment is often prescribed leading to further disease progression and associated morbidity. CONCLUSION: Myiasis secondary to C. rodhaini is a rare but important differential surgeons should consider in women presenting with an inflammatory breast lesion with a recent history of foreign travel to ensure timely diagnosis and treatment. Ultrasound imaging can be useful in confirming diagnosis and avoiding treatment delays.

Laparoscopic peritoneal lavage: our experience and review of the literature.

INTRODUCTION: Over the years various therapeutic techniques for diverticulitis have been developed. Laparoscopic peritoneal lavage (LPL) appears to be a safe and useful treatment, and it could be an effective alternative to colonic resection in emergency surgery. AIM: This prospective observational study aims to assess the safety and benefits of laparoscopic peritoneal lavage in perforated sigmoid diverticulitis. MATERIAL AND METHODS: We surgically treated 70 patients urgently for complicated sigmoid diverticulitis. Thirty-two (45.7%) patients underwent resection of the sigmoid colon and creation of a colostomy (Hartmann technique); 21 (30%) patients underwent peritoneal laparoscopic lavage; 4 (5.7%) patients underwent colostomy by the Mikulicz technique; and the remaining 13 (18.6%) patients underwent resection of the sigmoid colon and creation of a colorectal anastomosis with a protective ileostomy. RESULTS: The 66 patients examined were divided into 3 groups: 32 patients were treated with urgent surgery according to the Hartmann procedure; 13 patients were treated with resection and colorectal anastomosis; 21 patients were treated urgently with laparoscopic peritoneal lavage. We had no intraoperative complications. The overall mortality was 4.3% (3 patients). In the LPL group the morbidity rate was 33.3%. CONCLUSIONS: Currently it cannot be said that LPL is better in terms of mortality and morbidity than colonic resection. These data may, however, be proven wrong by greater attention in the selection of patients to undergo laparoscopic peritoneal lavage.

Analysis of long-term results after liver surgery for metastases from colorectal and non-colorectal tumors: A retrospective cohort study.

BACKGROUND: During the last decade, criteria for liver resection were extended thanks to surgical and oncological developments, thus increasing the number of surgeries for non-colorectal liver metastases. However, the real advantages of surgery in this category of patients remain debated, due to the few studies available in the literature. The present study aims to analyze liver surgery performed for metastatic disease at a single referral center, comparing outcomes of patients that underwent resections for colorectal and non-colorectal metastases. METHODS: The overall study period was January 2005-May 2015. A total of 170 patients were selected from the institutional database and then included in the analysis. Patients and tumors characteristics were reported. Overall survival and subgroup analyses based on different primary malignancies were performed. The Kaplan-Meier method was used. RESULTS: The mean age of the patients was 67.68 ± 10.98 years. Primary malignancies distribution resulted as follows: colorectal (77.1%), genitourinary (7.6%), neuroendocrine (5.3%), breast (4.7%), foregut (2.9%), melanoma (2.4%). The overall survival rates at 1, 3, 5 years, were 96.2%, 42.8% and 14.7%, respectively. The survival analysis showed a mean overall survival of 54 months in the colorectal metastases group vs 32 months in the non-colorectal liver metastases group (HR = 5.92, P = 0.015). CONCLUSION: Surgery for patients with non-colorectal liver metastases must be considered in the context of a multidisciplinary treatment where chemotherapy plays the main role. International guidelines and a specific consensus on this field are desirable to offer the best available therapy for the metastatic liver disease. ETHICS AND DISSEMINATION: This study is conducted in compliance with ethical principles originating from the Helsinki Declaration, within the guidelines of Good Clinical Practice and relevant laws/regulations. TRIAL REGISTRATION NUMBER: researchregistry898.

Robotic Total Gastrectomy With Intracorporeal Robot-Sewn Anastomosis: A Novel Approach Adopting the Double-Loop Reconstruction Method.

Gastric cancer constitutes a major health problem. Robotic surgery has been progressively developed in this field. Although the feasibility of robotic procedures has been demonstrated, there are unresolved aspects being debated, including the reproducibility of intracorporeal in place of extracorporeal anastomosis.Difficulties of traditional laparoscopy have been described and there are well-known advantages of robotic systems, but few articles in literature describe a full robotic execution of the reconstructive phase while others do not give a thorough explanation how this phase was run.A new reconstructive approach, not yet described in literature, was recently adopted at our Center.Robotic total gastrectomy with D2 lymphadenectomy and a so-called "double-loop" reconstruction method with intracorporeal robot-sewn anastomosis (Parisi's technique) was performed in all reported cases.Preoperative, intraoperative, and postoperative data were collected and a technical note was documented.All tumors were located at the upper third of the stomach, and no conversions or intraoperative complications occurred. Histopathological analysis showed R0 resection obtained in all specimens. Hospital stay was regular in all patients and discharge was recommended starting from the 4th postoperative day. No major postoperative complications or reoperations occurred.Reconstruction of the digestive tract after total gastrectomy is one of the main areas of surgical research in the treatment of gastric cancer and in the field of minimally invasive surgery.The double-loop method is a valid simplification of the traditional technique of construction of the Roux-limb that could increase the feasibility and safety in performing a full hand-sewn intracorporeal reconstruction and it appears to fit the characteristics of the robotic system thus obtaining excellent postoperative clinical outcomes.

New Trends in Acute Management of Colonic Diverticular Bleeding: A Systematic Review.

Colonic diverticular disease is the most common cause of lower gastrointestinal bleeding. In the past, this condition was usually managed with urgent colectomy. Recently, the development of endoscopy and interventional radiology has led to a change in the management of colonic diverticular bleeding.The aim of this systematic review is to define the best treatment for colonic diverticular bleeding.A systematic bibliographic research was performed on the online databases for studies (randomized controlled trials [RCTs], observational trials, case series, and case reports) published between 2005 and 2014, concerning patients admitted with a diagnosis of diverticular bleeding according to the PRISMA methodology.The outcomes of interest were: diagnosis of diverticulosis as source of bleeding; incidence of self-limiting diverticular bleeding; management of non self-limiting bleeding (endoscopy, angiography, surgery); and recurrent diverticular bleeding.Fourteen studies were retrieved for analysis. No RCTs were found. Eleven non-randomized clinical controlled trials (NRCCTs) were included in this systematic review. In all studies, the definitive diagnosis of diverticular bleeding was always made by urgent colonoscopy. The colonic diverticular bleeding stopped spontaneously in over 80% of the patients, but a re-bleeding was not rare. Recently, interventional endoscopy and angiography became the first-line approach, thus relegating emergency colectomy to patients presenting with hemodynamic instability or as a second-line treatment after failure or complications of hemostasis with less invasive treatments.Colonoscopy is effective to diagnose diverticular bleeding. Nowadays, interventional endoscopy and angiographic treatment have gained a leading role and colectomy should only be entertained in case of failure of the former.

Distal pancreatectomy with splenic preservation: A short-term outcome analysis of the Warshaw technique.

INTRODUCTION: Spleen-preserving left pancreatectomy (SPDP) with splenic vessels preservation (SVP) or without (Warshaw technique, WT) has been described with robotic, laparoscopy and open surgery. Nevertheless, significant data on medium- and long-term follow-up are still not available, since data in literature are scarce and the level of evidence is low. METHODS: In this retrospective study, we describe and compare short and medium term results of spleen-preserving distal pancreatectomy in eight patients. RESULTS: In WT group the duration and the intraoperative bleeding was superior than SVP group. The incidence of perigastric collateral vessels and presence of submucosal varices evidenced at CT scan was 66% in WT group, while only one case occurred in SVP group. DISCUSSION: The limit of laparoscopic approach is the fact that it needs advanced laparoscopic skills, which might result in intraoperative bleeding and splenectomy. The most of literature considered salvage WT intraoperatively performed in case of classical SVP and not only elective WT. The consequence is that there is no difference in immediate postoperative results (operative time, intraoperative bleeding, hospital stay) that are in favour of SVP because WT is performed only in case of failure in preserving the splenic vessels. In fact when this intervention is performed electively, the procedure time is reduced as well as the intraoperative bleeding. CONCLUSIONS: WT is safe and feasible, even if there are not definitive evidences that demonstrate it is superior to classic SVP. RCTs are needed to determine advantages and disadvantages of WT compared to the classic SVP.

Synchronous Orbital and Gastrointestinal Metastases from Breast Cancer: A Case Report and Review of Literature.

Breast cancer is the most common malignancy among women and is a significant cause of morbidity and mortality worldwide. With the advent of improved imaging techniques and screening programmes, only a small proportion of women present with metastatic disease. Metastases involving the gastrointestinal (GI) tract and orbit are rare occurrences. We describe the case of a woman with simultaneous GI and orbital metastases from breast cancer who initially presented with abdominal pain and blurred vision and also summarise a review of the literature.

Pneumoscrotum: report of two different cases and review of the literature.

Pneumoscrotum is the term used to describe the presence of air within the scrotum and includes scrotal emphysema as well as pneumatocele. The etiology varies; in some cases, pneumoscrotum may be due to life-threatening disease like pneumothorax or Fournier gangrene. Despite this, pneumoscrotum is a rarely debated issue. We present two different cases of pneumoscrotum and a review of the literature. The first case report is about a 29 year old male patient affected by Duchenne syndrome who showed pneumoscrotum after cardiopulmonary resuscitation that was performed for asphyxic crisis and cardiovascular arrest. We carried out local puncture with an 18-gauge needle, and the pneumoscrotum was successfully solved. The second case report is about a 56 year old male with pneumoscrotum due to Fournier gangrene who underwent radical exeresis of all necrotic tissues and drainage. This is why most of the scrotal skin and all of the penis skin were removed; as a result, the testicles, epididymis, and cavernosa corpora were externalized. On postoperative day one, the patient was feverless and underwent hyperbaric chamber therapy. No postoperative complications occurred. Accurate evaluation of the pneumoscrotum is always needed. Despite the benign course of most of the clinically evident pneumoscrotum cases, this condition should never be underestimated.

The measurement of amylase in drain fluid for the detection of pancreatic fistula after gastric cancer surgery: an interim analysis.

BACKGROUND: Pancreatic fistula is still one of the most serious and potential complications after D2-D3 distal and total gastrectomy (4% to 6%). Despite their importance, pancreatic fistulas still have not been uniformly defined. Amylase concentration of the drainage fluid after surgery for gastric cancer can be considered as a predictive factor of the presence of pancreatic fistula. METHODS: From January 2009 to April 2013, 53 patients underwent surgery for gastric cancer. Amylase concentration in the drainage fluid was measured on the first postoperative day and if it was ≥1,000 UI, it was measured again on the third postoperative day. Pancreatic fistula occurred in four cases (7.5%). Pancreatic fistulas were classified using the International Study Group on Pancreatic Fistula (ISGPF) criteria into different grades of severity. Two fistulas were Grade A, one was Grade B, and one was Grade C. RESULTS: Management of drainage tubes is still crucial after gastrectomy, not only for the likelihood of anastomotic leaks but also the eventual diagnosis and management of pancreatic fistula. High amylase drainage content and then the presence of the pancreatic fistula may be due to several causes: the operation itself when it includes splenectomy or pancreatic tail-splenectomy, the extended lymphadenectomy but even the 'gently and softly' pancreatic manipulation, according literature, may be a risk factor. CONCLUSIONS: The authors assessed amylase concentration in the drainage fluid collected from the left subphrenic cavity on POD1 and POD3 in 53 patients who had undergone curative gastrectomy for cancer and concluded that amylase drainage content >3 times the serum amylase was a useful predictive risk factor for pancreatic fistula. Our work is an interim analysis and the aim of this study is to increase the accrual of the number of patients to have a significant number. For this reason, a protocol for a multicenter trial will be designed to verify whether the systematic measurement of amylase in drain fluid is better than abdominal ultrasound for the detection of pancreatic fistula after gastric cancer surgery.

Road accident due to a pancreatic insulinoma: a case report.

Insulinoma is a rare pancreatic endocrine tumor, typically sporadic and solitary. Although the Whipple triad, consisting of hypoglycemia, neuroglycopenic symptoms, and symptoms relief with glucose administration, is often present, the diagnosis may be challenging when symptoms are less typical. We report a case of road accident due to an episode of loss of consciousness in a patient with pancreatic insulinoma. In the previous months, the patient had occasionally reported nonspecific symptoms. During hospitalization, endocrine examinations were compatible with an insulin-producing tumor. Abdominal computerized tomography and magnetic resonance imaging allowed us to identify and localize the tumor. The patient underwent a robotic distal pancreatectomy with partial omentectomy and splenectomy. Insulin-producing tumors may go undetected for a long period due to nonspecific clinical symptoms, and may cause episodes of loss of consciousness with potentially lethal consequences. Robot-assisted procedures can be performed with the same techniques of the traditional surgery, reducing surgical trauma, intraoperative blood loss, and hospital stays.

Robotic pancreaticoduodenectomy in a case of duodenal gastrointestinal stromal tumor.

BACKGROUND: Laparoscopic pancreaticoduodenectomy is rarely performed, and it has not been particularly successful due to its technical complexity. The objective of this study is to highlight how robotic surgery could improve a minimally invasive approach and to expose the usefulness of robotic surgery even in complex surgical procedures. CASE PRESENTATION: The surgical technique employed in our center to perform a pancreaticoduodenectomy, which was by means of the da Vinci™ robotic system in order to remove a duodenal gastrointestinal stromal tumor, is reported. CONCLUSIONS: Robotic technology has improved significantly over the traditional laparoscopic approach, representing an evolution of minimally invasive techniques, allowing procedures to be safely performed that are still considered to be scarcely feasible or reproducible.

Robotic distal pancreatectomy with or without preservation of spleen: a technical note.

BACKGROUND: Distal pancreatectomy (DP) is a surgical procedure performed to remove the pancreatic tail jointly with a variable part of the pancreatic body and including a spleen resection in the case of conventional distal pancreatectomy or not in the spleen-preserving distal pancreatectomy. METHODS: In this article, we describe a standardized operative technique for fully robotic distal pancreatectomy. RESULTS: In the last decade, the use of robotic systems has become increasingly common as an approach for benign and malignant pancreatic disease treatment. Robotic Distal Pancreatectomy (RDP) is an emerging technology for which sufficient data to draw definitive conclusions in surgical oncology are still not available because the follow-up period after surgery is too short (less than 2 years). CONCLUSIONS: RDP is an emerging technology for which sufficient data to draw definitive conclusions of value in surgical oncology are still not available, however this techniques is safe and reproducible by surgeons that possess adequate skills.

Cardiomyopathy in a male patient with neutropenia and growth delay.

Neutropenia encompasses a family of neutropenic disorders, both permanent and intermittent, ranging from severe (<500 neutrophils/mm(3)) to mild (500-1500 neutrophils/mm(3)), which may also affect other organ systems such as the pancreas, central nervous system, heart, muscle and skin. Neutropenia can lead to life-threatening pyogenic infections whose severity is roughly inversely proportional to the circulating neutrophil counts.When neutropenia is detected, an attempt should be made to establish the etiology, and to distinguish acquired forms (the most frequent, including post viral neutropenia and autoimmune neutropenia) and congenital forms (rare disorders) that may be either isolated or part of a complex rare genetic disease. We report on a male patient initially diagnosed with isolated neutropenia who later turned out to be affected with Barth syndrome, a rare complex inherited disorder.