Advanced stage empyemas in community-acquired pneumonia: how hospital re-organization during the Covid-19 pandemic affected the increase in surgically treated cases.

The cause of pleural empyema is bacterial pneumonia and three stages has been described in the evolution of this disease: exudative, fibrino-purulent and organizational phases. The first therapeutic intervention is the antibiotic therapy; where pharmacological therapy alone is not sufficient to eradicate the infection, it is also necessary a surgical treatment. Since the province of Piacenza having been in the epicenter area during the first Sars-Cov 2 pandemic wave in March 2020 and the number of patients with Covid-related pneumonia required invasive and non-invasive respiratory support, had a considerable organizational impact on pulmonology and respiratory unit, hindering an optimal treatment of the bacterial pneumonia both in community as well as in the hospital. Among the many "collateral" damages of the epidemiological wave of the infection with Sars Cov-2, we have been able to observe in our Hospital, also an increase of pulmonary empyemas diagnosed at an advanced stage for what we believe to be organizational and social causes directly related to the pandemic: in order to cope with the emergency the Unit of Pneumology has been since March nearly uninterruptedly dedicated to the exclusive treatment of covid patients so the pneumologist has been removed due to the need from outpatient and residential management of general pneumology.

Left diaphragmatic rupture in vehicle trauma: Report of surgical treatment and complications of two consecutive cases.

BACKGROUND AND AIMS: Diaphragmatic ruptures are associated with blunt abdominal or thoracic trauma and often occur in car and motorbike accident with a high energy impact. CASE PRESENTATION: We report two cases of patients victims of car and motorbike accidents that were referred to the Emergency Department of our Hospital in August and September 2017 for a politrauma. The patients were both diagnosed with a left diaphragmatic rupture with herniation of the stomach in the chest, and decomposed fractures of the ribs. One of the two patients reported a large abdominal wound with loss of substance in the site of the impact. Both patients underwent to open emergency surgery with primary repair of the phrenic rupture. The post-operative course was characterized by the occurrence of complications such as respiratory distress and emothorax for one of the patients. CONCLUSION: Traumatic rupture of the diaphragm can be associated to blunt or penetrating abdominal trauma in car and motorbike accident with a prevalence of the left-sided lesions. In patients with politrauma an associate rupture of the diaphragm should be always suspected especially in motor accident where high energy impact can generate a traumatic laceration of the respiratory muscle. The treatment of associate thoracic wall fractures to prevent weaning and respiratory distress in intubated patient should be discussed.

Swyer-James-MacLeod syndrome presenting as spontaneous pneumothorax in an adult: Case report and review of literature.

Swyer-James-MacLeod Syndrome (SJMS) is an uncommon, emphysematous disease characterized by obliteration of the small bronchioles, hypoplasia/or absence of pulmonary artery and peripheral vascular bed. It is most commonly diagnosed in childhood. Patients are often asymptomatic or they could suffer from symptoms of recurrent pulmonary infections. Spontaneous pneumothorax is a rare presentation of this syndrome. We report a case of a 42-year old female patient presented at our Emergency Department with complaints of dyspnea and pleuritic chest pain with a diagnosis of spontaneous pneumothorax in emphysematous disease. The diagnosis of SJMS is usually based on imaging and clinical findings rather than on the results of pathologic examination; indeed, asymptomatic adult patients with SJMS are often diagnosed after a chest radiograph obtained for another reason. High-resolution computed tomography (HRCT) seems to be the most appropriate technique for the diagnosis. SJMS can be associated with spontaneous pneumothorax which represent an emergency condition due to the underlying pathological disease. The surgical treatment of the affected lung should be considered when conservative approach is ineffective.

Giant solitary fibrous tumor of the pelvis: A case report and review of literature.

INTRODUCTION: Solitary fibrous tumors (SFTs) are rare spindle cells neoplasms most likely arising from mesenchymal cells. Usually they involve the pleura. Even if extra-thoracic SFTs are rare, lately they are diagnosed with increased frequency. CASE PRESENTATION: We describe the case of giant pelvic and retroperitoneal neoplasm, a rare solitary fibrous tumor, in a 51-year-old man that was admitted for abdominal pain. DISCUSSION: On CT a SFT appears usually as a smooth, lobulated mass with occasional calcifications, but the imaging differential diagnosis with other mesenchymal tumors is very difficult, if not impossible. CONCLUSION: The histological and immune-histochemical features of SFTs are helpful for the differential diagnosis. The malignant potential of this cancer is low, but it is very important to perform an optimized surgery and a close follow up in the patient. We believe that this case is particularly interesting and complex because of the difficulty of predicting the future biological behavior.

Breaking the habit in the Covid Era: how is changed the routine of a surgeon in mostly affected italian province, Piacenza, Emilia Romagna.

The Sars-Cov2 Pandemic in Italy gave rise in Piacenza, northern Emilia, to one of the most extensive contagions ever recorded in Italy, the area being hit from the beginning of February, with all its dramatic force and enormous impact in terms of human lives, upsetting social lives. Piacenza is only few kilometers away from what was unexpectedly identified as the first known outbreak in the Western world, registered in Codogno, a small town in the province of Lodi, where the first verified Italian case of the infection Covid- 19 was isolated.Due to the advancement of the contagion and the exponential increase of Covid cases which required hospitalization all the surgical wards of our Hospital, except for the Emergency Surgery of the Hospital's central hub "Guglielmo da Saliceto" of Piacenza, were converted into Covid wards with various degrees of management care on behalf of the personnel, as also the operating theatres became new ICU units. Consequently, the professional life habits of the surgeons in general have radically changed: the surgeons have been working for about 70% of their working hours in internist support activities for the management of Covid-correlated pneumonia patients.Since then however, many questions have arisen during our daily reflections regarding the need for future planning of our surgery procedures: how much longer can we delay the planning of our selected surgery? Which epidemiological parameters, and other, should we identify in order to start up selected general surgery?For how long can selected surgery be deferred without compromising outcomes and mid to long term mortality in oncological patients in our province, considering also the diagnostic-therapeutic delays in these exceptional months of the Covid era?

Ladd's band in the adult, an unusual case of occlusion: Case report and review of the literature.

INTRODUCTION: Malrotation of gut is a congenital anomaly of foetal intestinal rotation and it is mostly discovered in early childhood as acute intestinal obstruction. This condition is very rare and often silent in adults. PRESENTATION OF CASE: We present a case of 44-year-old woman admitted with acute abdominal pain. The abdominal CT scan showed ileal conglomerate loops with thickened walls filled of liquid in the right iliac side. Laparotomic Ladd's procedure was performed successfully with division of Ladd's band, adhesiolysis, reconstruction of Treitz's ligament, small bowel resection and Merckel's diverticulum removal. The patient made an unremarkable recovery. DISCUSSION: We discuss the rarity of intestinal malrotation in adulthood and made a literature review comparison of the therapeutic options available. CONCLUSION: Intestinal malrotation is a rare entity and adult presentation is even rarer. Some cases are asymptomatic, but when symptomatic a volvulus should be promptly suspected to avoid complications such as bowel ischemia.

Asymptomatic pneumoperitoneum in pneumatosis coli: A misleading operative indication.

INTRODUCTION: Pneumatosis cystoides intestinalis (PCI) is a rare clinical pathology characterized by sub-mucosal and/or sub-serous cysts of free gas, forming cystic lesions usually ranging from 0.5 to 2.0 cm in size within the gastrointestinal tract. About 3% of patients with PCI develop complications such as pneumoperitoneum, intestinal volvulus, obstruction, or hemorrhage, these cases need immediate surgical intervention. Cyst rupture can produce peritoneal irritation and pneumoperitoneum. PRESENTATION OF CASE: A 65-years-old woman was admitted to the Emergency Department for epileptiform convulsions. Her medical hystory included epilepsy, diabetes, lichenoid dermatitis, hypothyroidism, severe cognitive impairment. Abdominal CT scan revealed a dilated large intestine with parietal pneumatosis from the appendix to the transverse colon associated to extensive pneumoperitoneum. The patient underwent emergency laparotomy which revealed the presence of gas within the wall of right and transverse colon and distension of great omentum. No resection was needed as normal blood supply to the bowel present. DISCUSSION: Pneumatosis coli can be both asymptomatic or life-threatening condition associated to bowel infarction; this situation can mimic a bowel perforation causing pneumoperitoneum - that sometimes is a non-surgical pneumoperitoneum - and it could be a misleading indication to surgical exploration especially in the case of uncertain origin of a septic shock. CONCLUSIONS: We report a case of pneuomoperitoneum due to PCI. Surgical intervention was required for patient's conditions and unclear origin of the sepsis.

Rapunzel syndrome: an infrequent cause of severe iron deficiency anemia and abdominal pain presenting to the pediatric emergency department.

BACKGROUND: Iron deficiency anemia (IDA) and abdominal pain are commonly seen in a pediatric emergency department (8 and 18% incidence respectively in our center). They are manifestations of a wide variety of diseases ranging from benign to immediately life-threatening. Trichobezoar is an under-diagnosed entity that has to be considered in children and adolescents, expecially female, suffering from trichotillomania (compulsion to pull hair) and trichophagy (compulsion to swallow hair). When undiagnosed, gastric bezoars may cause gastric ulceration, perforation, haemorrhage and obstruction. CASE PRESENTATION: To underline the importance of including this pathology in the differential diagnosis of IDA and abdominal pain, we present the case of a 14 year-old girl with a huge trichobezoar which completely filled the stomach and extended into the small bowel. Since trichobezoar has an extension to the small bowel, it is classified as Rapunzel syndrome. As the bezoar couldn't be removed by endoscopy, the girl underwent surgical intervention. The patient passed through a gradual re-feeding, with iron and vitamins supplementation, and through a psychiatric counselling. CONCLUSION: The Rapunzel syndrome is a rare entity that may be complicated by life-threatening events. A prompt diagnosis and an appropriate therapy can reduce comorbidities. Gradual re-feeding with supplementation of micronutrients allows adequate catch-up weight with normalization of haematochemical nutritional parameters. Since many of these patients suffer from psychiatric pathology such as PICA with emotional problems and mental retardation, psychological/psychiatric counselling plays an important role in order to prevent bezoar recurrence.

Prognostic factors and outcome of resected patients for gastrointestinal stromal tumors.

BACKGROUND/AIMS: The aim of this study was to analyze the outcome of 33 patients with primary gastrointestinal stromal tumors (GISTs) who were observed and treated in a single teaching hospital and followed up prospectively. METHODOLOGY: Thirty-three GISTs patients (21 male; 12 female; mean age: 57 +/- 12 years; range: 23-76 years) between June 1994 and October 2004, were reviewed retrospectively. Patient, tumor, and treatment variables were analyzed to identify patterns of tumor relapse and factors affecting survival. RESULTS: Of 33 patients, 30 patients (91%) had primary tumor without metastasis, and all of them underwent complete surgical resection of gross disease. Three patients (9%) had metastasis. Among patients radically resected, the 5-year actuarial survival rate was 85%, and the disease-free survival was 76%. Among patients resected for cure, there were 6 recurrences. The mean time to recurrence was 22 +/- 11 months (range: 4-36 months), and liver was the prevalent site for relapsing disease (n = 5; 83%). After recurrence, survival at 2 and 3 years was 44% and 0%, respectively. CONCLUSIONS: GISTs are uncommon sarcomas. Tumor recurrence tends to be intra-abdominal. Investigational protocols are indicated to reduce the rate of recurrence after resection and to improve the outcome for patients with GIST.

The influence of type of operation for distal rectal cancer: survival, outcomes, and recurrence.

BACKGROUND/AIMS: This study analyzed the results of treatment of rectal cancer (tumor within 12 cm of the anal verge) with different techniques. METHODOLOGY: Two hundred and sixty-four patients who had undergone elective curative surgical resection of rectal cancer within 12cm of the anal verge were evaluated. The operative data and follow-up data were collected prospectively. Comparisons were made between patients who had different surgical procedures. RESULTS: The overall peroperative mortality rate was nil, and the morbidity 39.4%. Local recurrence occurred in 21 of the patients with a median follow-up of 34 months (range: 5-105 months). The 3-year actuarial local recurrence rates for double-stapled anastomosis, low straight anastomosis and APR were 25%, 6%, and 5%, respectively. The local recurrence rate was significantly higher for double-stapled low anterior resection than for the other types of operation (p = 0.013). On multivariate analysis reconstruction with Knight-Griffen anastomosis (p = 0.013) and tumor distance from the anal verge <6 cm (p = 0.001), were associated with local recurrence but only stage was a significant prognosticator of overall survival (p = 0.012). CONCLUSIONS: Following total mesorectal excision, the local recurrence rate was higher in patients treated with double-stapled low anterior resection than in those with termino-terminal low anterior resection or APR; survival rates were similar in these groups.

Surgical treatment of advanced colorectal cancer in the elderly.

The aim of the study was to compare the short and long-term outcomes of older and younger colorectal cancer patients with advanced disease resected with a curative intent. Six hundred and ninety-two patients were analysed. Four hundred and seventy-nine patients were younger than 70 years (Group 1), and 213 were 70 years of age or above (Group 2). The overall perioperative mortality rate in the younger group was 0.8% (n = 7), as against 1.4% (n = 3) in the elderly group (p = NS). The morbidity rates were 35% and 42%, respectively (p = NS). At univariate analysis, the elderly patients had a worse overall survival compared to the younger group, when only patients undergoing postoperative chemo-radiotherapy were considered (54% vs 67% overall survival at 5 years; p = 0.03). Using logistic regression analysis, tumour stage (p < 0.0001) and radicality of surgery (p < 0.0001) correlated significantly with overall survival rates in the elderly. Colorectal surgery for malignancy can be performed safely in the elderly with acceptable morbidity and mortality rates and long-term survival.

Results of treatment of distal rectal carcinoma since the introduction of total mesorectal excision: a single unit experience, 1994-2003.

BACKGROUND AND AIMS: This study reviewed the results of surgery for distal rectal cancer (where the tumour was within 6 cm of the anal verge) following the introduction of total mesorectal excision for rectal cancer in one institution. PATIENTS AND METHODS: One hundred and fifty-three patients who had undergone elective curative surgical resection of rectal cancer within 6 cm of the anal verge were included. The demographic, operative and follow-up data were collected retrospectively. Comparisons were made between patients who had different surgical procedures. RESULTS: The overall operative mortality rate was nil, and the morbidity 41%. With a mean follow-up of 37 months (range 5-100 months), local recurrence occurred in 18 of the patients. The 5-year actuarial local recurrence rates for double-stapled anastomosis, low-strength anastomosis and abdominoperineal resection (APR) were 39, 17 and 11% respectively. The local recurrence rate was significantly higher for double-stapled low anterior resection than for the other types of operation (P=0.007). On multivariate analysis type of surgery (P=0.025) and tumour stage (P=0.043), were associated with local recurrence, but only stage was a significant prognosticator of overall survival (P=0.0006). CONCLUSION: With the practice of total mesorectal excision, APR was still necessary in 40% of patients with rectal cancer within 6 cm of the anal verge. The local recurrence rate was lower in patients treated with APR than in those with double-stapled low anterior resection; however, survival rates were similar in these two groups.