COVID-19 outbreak and acute cholecystitis in a Hub Hospital in Milan: wider indications for percutaneous cholecystostomy.

BACKGROUND: COVID-19 pandemic has impacted the Italian National Health Care system at many different levels, causing a complete reorganization of surgical wards. In this context, our study retrospectively analysed the management strategy for patients with acute cholecystitis. METHODS: We analysed all patients admitted to our Emergency Department for acute cholecystitis between February and April 2020 and we graded each case according to 2018 Tokyo Guidelines. All patients were tested for positivity to SARS-CoV-2 and received an initial conservative treatment. We focused on patients submitted to cholecystostomy during the acute phase of pandemic and their subsequent disease evolution. RESULTS: Thirty-seven patients were admitted for acute cholecystitis (13 grade I, 16 grade II, 8 grade III). According to Tokyo Guidelines (2018), patients were successfully treated with antibiotic only, bedside percutaneous transhepatic gallbladder drainage (PC) and laparoscopic cholecystectomy (LC) in 29.7%, 21.6% and 48.7% of cases respectively. Therapeutic strategy of three out of 8 cases, otherwise fit for surgery, submitted to bedside percutaneous transhepatic gallbladder drainage (37.5%), were directly modified by COVID-19 pandemic: one due to the SARS-CoV-2 positivity, while two others due to unavailability of operating room and intensive care unit for post-operative monitoring respectively. Overall success rate of percutaneous cholecystostomy was of 87.5%. The mean post-procedural hospitalization length was 9 days, and no related adverse events were observed apart from transient parietal bleeding, conservatively treated. Once discharged, two patients required readmission because of acute biliary symptoms. Median time of drainage removal was 43 days and only 50% patients thereafter underwent cholecystectomy. CONCLUSIONS: Percutaneous cholecystostomy has shown to be an effective and safe treatment thus acquiring an increased relevance in the first phase of the pandemic. Nowadays, considering we are forced to live with the SARS-CoV-2 virus, PC should be considered as a virtuous, alternative tool for potentially all COVID-19 positive patients and selectively for negative cases unresponsive to conservative therapy and unfit for surgery.

Surgical Strategy During the COVID-19 Pandemic in a University Metropolitan Hospital in Milan, Italy.

The COVID-19 pandemic has spread rapidly, forcing some drastic changes not only in our daily lives, but also in our clinical and surgical activities. Given our extensive Italian experience, we hereby describe how our surgical unit activity has changed and how, in some cases, it was necessary to modify surgical strategies. We hope our experience can be shared with our global colleagues who are suffering under similar condition.

Intraoperative ultrasound for prediction of hepatocellular carcinoma biological behaviour: Prospective comparison with pathology.

BACKGROUND & AIMS: Preoperative prediction of both microinvasive hepatocellular carcinoma and histological grade of hepatocellular carcinoma is pivotal to treatment planning and prognostication. The aim of this study was to evaluate whether some intraoperative ultrasound features correlate with both the presence of same histological patterns and differentiation grade of hepatocellular carcinoma on the histological features of the primary resected tumour. METHODS: All patients with single, small hepatocellular carcinoma that underwent hepatic resection were included in this prospective double-blind study: the intraoperative ultrasound patterns of nodule were registered and compared with similar histological features. RESULTS: A total of 179 patients were enclosed in this study: 97 (54%) patients (34% in HCC ≤2 cm) had a microinvasive hepatocellular carcinoma at ultrasound examination, while 82 (46%) patients (41% in HCC ≤2 cm) at histological evaluation. Statistical analysis showed that diameters ≤2 cm, presence of satellites and microinvasive hepatocellular carcinoma at ultrasound examination were the variables with the strongest association with the histological findings. In the multivariate analysis, the vascular microinfiltration and infiltrative hepatocellular carcinoma aspect were independent predictors for grading. CONCLUSIONS: In patients with cirrhosis and hepatocellular carcinoma, the prevalence of microinvasive hepatocellular carcinoma is high, even in cases of HCC ≤2 cm. Intraoperative ultrasound findings strongly correlated with histopathological criteria in detecting microinvasive patterns and are useful to predict neoplastic differentiation. The knowledge of these features prior to treatment are highly desired (this can be obtained by an intraoperative ultrasound examination), as they could help in providing optimal management of patients with hepatocellular carcinoma.

Effect of Age (over 75 Years) on Postoperative Complications and Survival in Patients Undergoing Hepatic Resection for Hepatocellular Carcinoma.

BACKGROUND: Thanks to technical advancement in surgery for hepatocellular carcinoma (HCC), hepatic resection (HR) for elderly HCC patients has become safer. However, elderly patients may have shorter long-term survival after surgery if compared with younger patients because of their expected life span. The aim of the present study was to evaluate clinical outcomes and safety after HR in HCC patients aged >75 years (older) compared with HCC patients aged <75 years (younger). METHOD: One hundred sixty-eight patients who underwent HR for HCC from 1998 to 2015 in our Center were analyzed using a prospective database. Complications, disease-free survival rates, and cumulative survival rates were compared between the two groups. RESULTS: During the immediate postoperative period, no differences were found about liver-related complications, hospital stay and 90-day mortality. However, older patients had more complications in class II or higher (Clavien classification) (p = 0.017). Although disease-free survival in both groups was similar (p = 0.099), overall survival was worse in the elderly group (p = 0.024). On multivariate analysis, only age ≥75 years was significantly related to overall survival. CONCLUSION: If elderly patients with liver cirrhosis and HCC are appropriately selected and evaluated, they might have favorable prognoses after HR.

Effect of nitrogen fertilisation on the overall quality of minimally processed globe artichoke heads.

BACKGROUND: Although nitrogen (N) fertilisation is essential for promoting crop yield, it may also affect the produce quality. Here, the influence of three N fertiliser rates (0 kg ha-1 as a control, 200 kg ha-1 and 400 kg ha-1 referred to as N0 , N200 and N400, respectively) on the overall quality of minimally processed globe artichoke heads was investigated during refrigerated storage for 12 days. RESULTS: Throughout the storage time, N fertilised samples had higher inulin contents than those unfertilised. In addition, the respiratory quotient of N200 and N400 samples was 2-fold and 2.5-fold lower than N0 ones, whose values were close to the normal range for vegetables. All the samples reported good microbiological standards, although N200 and N400 achieved lower mesophilic and psychotropic counts than N0 throughout the storage time. After 8 and 12 days of refrigerated storage, the N200 samples showed the highest scores of positive sensory descriptors. CONCLUSION: A fertiliser level of 200 kg N ha-1 is suitable for obtaining minimally processed globe artichoke heads with good nutritional, sensory and microbiological quality, characterised by low endogenous oxidase activities. Proper packaging systems and procedures are, however, crucial for extending the product shelf-life and, thus, promoting its exportation on a wider scale. © 2016 Society of Chemical Industry.

Total or partial anatomical resection of segment 8 using the ultrasound-guided finger compression technique.

BACKGROUND: A new surgical technique to define intra-operatively segmental and subsegmental areas of the liver using ultrasound-guided bimanual liver compression has been recently described. However, this technique does not allow disclosure of the subsegmental ventral (S8v) and dorsal (S8d) portions of segment 8 (S8). Another technique that overcomes these limitations is described. METHODS: Six patients with hepatoma, cirrhosis and no evidence of portal vein thrombosis were submitted to the procedure. Demarcation of the resection area was achieved using ultrasound-guided finger compression of the S8 subsegmental portal branches (P8v and P8d). RESULTS: The procedure was feasible in all patients and demarcation was always obtained within 1 min of bimanual ultrasound-guided compression. In one patient, the entire S8 was resected. In the remaining five patients, the dorsal (four patients) or the ventral (one patient) portion was removed, respectively. There was no mortality or morbidity and no blood transfusions were administered. CONCLUSIONS: Disclosure of the subsegmental portions of S8 using the ultrasound-guided compression technique was feasible, safe and effective, and represents the completion of the ultrasound-guided compression technique for performing segmental and subsegmental anatomical resection of the liver.

Polyphasic characterization of bacterial community in fresh cut salads.

In the present work we describe a polyphasic study of bacterial community in fresh cut salads packaged under ordinary and modified atmospheres. Samples of fresh cut salads were aseptically collected at 0, 3, and 6 days of storage and analysed both by culture-dependent and -independent methods. DNA extracted from fresh cut salad samples was used as a template for PCR amplification of 16 S rRNA gene; the PCR products were analyzed by denaturing gradient gel electrophoresis (DGGE); finally, clone libraries of 16 S rRNA gene from the fresh cut salad was constructed. Results of plating count revealed a significant increase of all microbial loads in fresh-cut salad samples packaged in OA and that the microbial growth of the different groups was significantly affected by the conditions applied for MA packaging. A constant presence, throughout storage, of the pathogenic bacteria in all the fresh-cut salads samples was highlighted by PCR-DGGE analysis. Therefore, the polyphasic approach used in the present study allowed us to characterize the main species involved in the fresh cut salad products and to better understand their dynamics throughout storage.