Percutaneous cholecystostomy and acute cholecystitis: how, when and why.

AIM: Acute cholecystitis (AC) is one of the most frequent pathologies treated in urgency. An immediate surgical intervention for frail patients who are ineligible for surgery as a result of severe co-morbidities is questionable. The aim of this study is to investigate the safety and the management of percutaneous cholecistostomy (PC) in high-risk surgical patients. MATERIALS AND METHODS: In the period of time January 2015 - May 2021 we observed 1105 patients admitted with acute cholecystitis in our Department. In the group with severe cholecystitis (160 patients, 14.48%), 137 (12.39%) were submitted to immediate surgery, and 23 (4.8%) were treated with PC. All these patients were non-responding to conservative management. Initially, we used PC as a definitive treatment; from the second half of 2018 PC was implemented as a bridge to surgery. RESULTS: Clinically, symptoms resolved in all the 23 patients. Mortality was nihil and no complication was recorded. PC was used as definitive treatment in 14 cases, wheres in 9 patients PC was intended as a-bridge-to-surgery treatment, and was followed by cholecystectomy. DISCUSSION: 2017 guidelines, of World Society of Emergency Surgery recommended PC as a safe and effective management of AC in patients with multiple comorbidities. In this group of patients PC achieves a prompt resolution of clinical symptoms and is superior to conservative management. There are no absolute contraindications to PC. CONCLUSIONS: PC is a safe and less invasive treatment of AC for patients with prohibitive surgical risk. It may be used as bridge to surgery to switch high-risk for moderate-risk patients, more suitable for a safe and definitive surgical treatment. KEY WORDS: Acute cholecystitis, High-risk surgical patients, Percutaneous cholecystostomy.

Blunt splenic trauma 2.0. State of the art.

AIM: To evaluate the advantages and potential risks of "Non Operative Management" (NOM) in order to redifine the technique into the true gold standard and to extend its application to the emergency care of blunt splenic trauma. MATERIALS AND METHODS: Blunt trauma cases treated between 2004 and 2019 have been retrospectively evaluated. Every patient has been distributed at the hospital admission in 3 different groups: stable, unstable and transient responder according to ATLS. NOM exclusion criteria were only introduced in 2013: we therefore assessed datas before and after this year. RESULTS: Over a period of 15 years, approximately 6 patients per year were admitted to our hospital with a spleen injury. After the introduction of the NOM protocol in 2013, the proportion of splenectomies progressively decreased. This rate also increased for higher injury grades. The overall number of patients who underwent NOM was 40 (43%), but while between 2004 and 2012 only 25% of patients were managed with NOM, between 2013 and 2019 70.3% of patients were treated with NOM. CONCLUSIONS: Nowadays any blunt splenic trauma could, theoretically, undergo NOM, regardless of the grade of the injury; the only strict criteria for OM should be haemodynamic instability; this assumption depends, of course, on hospital's human and technological resources. KEY WORDS: Non operative management, Splenic trauma, Splenectomy.

Ideal level of ligation of the inferior mesenteric artery. An old debate for a current surgical approach.

AIM: The ideal level of ligation of the inferior mesenteric artery (IMA) during resection for colorectal cancer is still controversial. The aim of this study was to demonstrate the real advantages and, above all, the adequacy of oncological staging after a low ligation of the IMA with additional LN retrieval in patients undergoing surgery for colorectal cancer. MATERIALS AND METHODS: Between January 2013 and December 2020, 157 patients who underwent curative resection of a primary colorectal tumor were retrospectively included: 64 patients underwent high ligation of the IMA and 93 patients underwent low ligation of the IMA with additional LN retrieval. Results - Mean number of lymphnodes harvested (the median number of harvested nodes was 16.2 in "high ligation" group vs 15.4 in "low ligation" group), operation time (272 minutes vs 293 minutes), intraoperative blood loss (40 cc vs 53 cc) and recovery time (median postoperative hospitalization was 6.4 days in both groups) were not significantly different between the groups. DISCUSSION: High ligation of the IMA preserves an adequate length of the colon to perform a successful anastomosis and facilitates apical LN dissection. However, it may be associated with an increased risk of anastomotic leakage. Low ligation of the IMA is less invasive and it is associated with a better preservation of genitourinary function and, futhermore, with an accurate oncological clearance. CONCLUSION: Low ligation of the IMA with additional LN retrieval might be an oncologically safe and less invasive procedure in the surgical management of patients with colorectal cancer. KEY WORDS: Colorectal cancer, Inferior mesenteric artery, Ligation.

Cholangioscopic management of intrahepatic papillomatosis unsuitable for surgical treatment.

INTRODUCTION: Biliary papillomatosis can arise in any tract of the biliary three and is characterized by multiple papillary proliferation of the epithelial cells. CASE REPORT: A 65 year old woman was diagnosed been affected by biliary papillomatosis after many recurrent cholangitis episodes. Liver transplantation was excluded because of neoplastic degeneration with systemic involvement. After a percutaneous drainage and with palliative intent we performed an Argon plasma coagulation of the papillary lesions. DISCUSSION: Clinical behaviour consists of recurrent cholangitis episodes and obstructive jaundice. There aren't specific radiological features, only mucobilia observed during an ERCP is pathognomonic. Biliary papillomatosis grow according to the sequence adenoma-carcinoma with malignant transformation and poor prognosis due to multifocality and high recurrence rate. Radical surgery and liver transplantation represents the gold standard. Among palliative procedures must be considered percutaneous management with drainage and stenting, and intraluminal brachytherapy with I 192. CONCLUSION: We propose a palliative treatment with cholangioscopic Argon plasma coagulation of the biliary lesions that can be performed during a surgical exploration or a percutaneous management.

Leiomyosarcoma of the inferior vena cava. Report of two cases and review of the literature.

INTRODUCTION: Leiomyosarcoma (LMS) occurs most frequently in the inferior vena cav (IVC). Since Perl's first description in 1871, about 300 cases of IVX have been reported in English literature. The Authors present their personal experience of two case of IVC leiomyosarcoma treated in their Institution. PATIENTS AND METHODS: Clinical and pathologic data, surgical management, ourcomes and follow-up of two patients admitted nb the Authors' Division respectively on February and November 2004 were collected. RESULTS: There were a 49-years-old female with rare epigastric pain and a 42-years-old female with one-month history of abdominal discomfort and weight loss. After preoperative evaluation, both of the patients had localised and resectable tumors and underwent radical surgical excision, with prosthetic replacement of the IVC in the first patient and ligation of the IVC in the other one. The first patient is still alive but in an advanced disease. The second patient died of recurrence at seven months. DISCUSSION: LMS of IVC is a rare tumor. The diagnosis is often delayed because of non-specificic symptoms. Radical resection with surgical margins free of tumor is the treatment of choice. The extent of venous resection does not seem to affect the survival. The type of IVC reconstruction is based on the extent of venal wall involvement. The prognosis is often poor because of tumor recurrence and/or metastatic disease. The role of chemo and radio therapy is not clear yet. CONCLUSION: Long term survival is related to an extensive surgery, being surgical margins free of tumor the only prognostic factor with significant influence on patients survival.

A proposal for thyroid surgery: criteria to identify the references of endocrine surgery.

Indicators of effectiveness and quality of care are needed to improve the outcomes in many surgical fields. International and national studies in thyroid surgery have not clearly documented an association between number of cases and outcome quality, but it is essential for the figure of a highly experienced surgeon, able to provide proof of positive outcomes. Therefore, we try to underline the structural and technical requirements in thyroid surgery. Moreover, the need for an accreditation program is outlined.

Abdominal aortic aneurysm and concomitant malignancy: what treatment?

UNLABELLED: The association of neoplasm and abdominal aortic aneurysm (AAA), although rare, may represents a therapeutic dilemma. MATERIALS AND METHODS: Between January 1990 and December 2004 in our departement 127 patients were submitted because of an AAA, in 8 cases there was an association with a neoplasm, in the greater part being a colon cancer. In 3 cases we performed a one stage surgery, in 1 case the chose was for a two stage surgery, for 3 patients we opted for an endovascular treatment by an endograft, in 1 case a pancreatic cancer was diagnosed 3 months after the prosthetic replacement of an AAA and there were no surgical indications because of the patient was in an advanced neoplastic stage. RESULTS: There weren't any prosthetic infection or more serious complications. The endovascular treatments were performed successfully without complications after few days being followed by cancer's resection. DISCUSSION: In case of this association the prognosis is related to neoplasm's stage. Timing depednds on the pathology that has the higher risk of short-term complication. Since Nineties author's reports in Literature about one stage surgery are more frequent, while now endovascular methods open new chances. CONCLUSIONS: One stage surgery is a safe option in case of association between AAA and cancer. We think that a good porpouse is the use of a vascular endograft in aneurysmal treatment followed, after few days, by cancer's resection.