Adaptation strategies and neurophysiological response in early-stage Parkinson's disease: BioVRSea approach.

Introduction: There is accumulating evidence that many pathological conditions affecting human balance are consequence of postural control (PC) failure or overstimulation such as in motion sickness. Our research shows the potential of using the response to a complex postural control task to assess patients with early-stage Parkinson's Disease (PD). Methods: We developed a unique measurement model, where the PC task is triggered by a moving platform in a virtual reality environment while simultaneously recording EEG, EMG and CoP signals. This novel paradigm of assessment is called BioVRSea. We studied the interplay between biosignals and their differences in healthy subjects and with early-stage PD. Results: Despite the limited number of subjects (29 healthy and nine PD) the results of our work show significant differences in several biosignals features, demonstrating that the combined output of posturography, muscle activation and cortical response is capable of distinguishing healthy from pathological. Discussion: The differences measured following the end of the platform movement are remarkable, as the induced sway is different between the two groups and triggers statistically relevant cortical activities in α and θ bands. This is a first important step to develop a multi-metric signature able to quantify PC and distinguish healthy from pathological response.

Improving Prosthetic Selection and Predicting BMD from Biometric Measurements in Patients Receiving Total Hip Arthroplasty.

There are two surgical approaches to performing total hip arthroplasty (THA): a cemented or uncemented type of prosthesis. The choice is usually based on the experience of the orthopaedic surgeon and on parameters such as the age and gender of the patient. Using machine learning (ML) techniques on quantitative biomechanical and bone quality data extracted from computed tomography, electromyography and gait analysis, the aim of this paper was, firstly, to help clinicians use patient-specific biomarkers from diagnostic exams in the prosthetic decision-making process. The second aim was to evaluate patient long-term outcomes by predicting the bone mineral density (BMD) of the proximal and distal parts of the femur using advanced image processing analysis techniques and ML. The ML analyses were performed on diagnostic patient data extracted from a national database of 51 THA patients using the Knime analytics platform. The classification analysis achieved 93% accuracy in choosing the type of prosthesis; the regression analysis on the BMD data showed a coefficient of determination of about 0.6. The start and stop of the electromyographic signals were identified as the best predictors. This study shows a patient-specific approach could be helpful in the decision-making process and provide clinicians with information regarding the follow up of patients.

Total sacrectomy for recurrent rectal cancer - A case report featuring technical details and potential pitfalls.

INTRODUCTION: Total sacrectomy for recurrent rectal cancer is controversial. However, recent publications suggest encouraging outcomes with high sacral resections. We present the first case report describing technical aspects, potential pitfalls and treatment of complications associated with total sacrectomy performed as a treatment of recurrent rectal cancer. PRESENTATION OF CASE: A fifty-three year old man was previously treated at another institution with a low anterior resection (LAR) followed by chemo-radiation and left liver tri-segmentectomy for metastatic rectal cancer. Three years following the LAR, the patient developed a recurrence at the site of colorectal anastomosis, manifesting clinically as a contained perforation, forming a recto-cutaneous fistula through the sacrum. Abdomino-perineal resection (APR) and complete sacrectomy were performed using an anterior-posterior approach with posterior spinal instrumented fusion and pelvic fixation using iliac crest bone graft. Left sided vertical rectus abdominis muscle flap and right sided gracilis muscle flap were used for hardware coverage and to fill the pelvic defect. One year after the resection, the patient remains disease free and has regained the ability to move his lower limbs against gravity. DISCUSSION: The case described in this report features some formidable challenges due to the previous surgeries for metastatic disease, and the presence of a recto-sacral cutaneous fistula. An approach with careful surgical planning including considerationof peri-operative embolization is vital for a successful outcome of the operation. A high degree of suspicion for pseudo-aneurysms formation due infection or dislodgement of metallic coils is necessary in the postoperative phase. CONCLUSION: Total sacrectomy for the treatment of recurrent rectal cancer with acceptable short-term outcomes is possible.A detailed explanation to the patient of the possible complications and expectations including the concept of a very high chancefor recurrence is paramount prior to proceeding with such a surgery.

Predictive value of bacterial analysis of laparotomy wounds.

BACKGROUND: Despite improvements in antibiotic prophylaxis, surgical site infections represent the most common postoperative complication with important clinical consequences for patients. AIM: The hypothesis that a bacterial analysis of the surgical wound in the operating room could predict the likelihood of developing a clinical infection, and might allow a tailored and preemptive approach, aimed to reduce the consequences of an infection, seems appealing. We would like to present a prospective study on the predictive value of the bacterial analysis of laparotomy wounds. MATERIAL OF STUDY: Seventy eight prospective patients undergoing surgery were included in the study. To evaluate the risk factors associated with increased rate of wound infection, we performed a bacterial analysis of the wound. RESULTS: 48 patients out of 78 (61%) had positive cultures. 23 patients out of 32 patients (72%) who didn't receive antibiotic prophylaxis were positive to the wound culture whereas 25 patients out of 46 patients (54%) grew positive cultures in the group of patients that received antibiotic prophylaxis. None of the 30 patients with negative cultures developed clinical infection. Only 6 patients out of 48 patients who had positive cultures (12.5%) developed wound infection. Clinical infection occurred in 5 patients who had gram-negative contamination of the wound. No clinical infection occurred in patients who had gram-positive contamination. CONCLUSION: Wound cultures and their positivity are predictive tools to identify the patients that are at risk to develop wound infection. The positive predictive value of the bacterial analysis of the wound was 12.5%. KEY WORDS: Abdominal surgery, Bacterial analysis, Wound infection.

Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-years experience in a district hospital.

BACKGROUND: Laparoscopic appendectomy is not yet unanimously considered the "gold standard" in the treatment of acute appendicitis because of its higher operative time, intra-abdominal abscess risk, and costs compared to open appendectomy. This study aimed to compare outcomes and cost of laparoscopic and open appendectomy in a district hospital. METHODS: A retrospective analysis of 230 patients who underwent appendectomy at the Division of General Surgery of the Civil Hospital of Ragusa, Italy, from May 2008 to May 2012 was performed. The variables analyzed included patients data (age, gender, previous abdominal surgery, preoperative WBC count, duration of symptoms, ASA risk score), rate of uncomplicated or complicated appendicitis, operative time, postoperative complications, length of hospital stay, and total costs. The patients were divided in two groups according to the surgical approach and compared for each variable. The results were analyzed using the t Student test for quantitative variables, and the Chi-square test with Yates correction and Fisher exact test for categorical. RESULTS: Laparoscopic appendectomy was performed in 139 patients, open appendectomy in 91. Two cases (1.4%) were converted to open procedure and included in the laparoscopic group data. Patient data and rate of complicated appendicitis were similar in the two study groups. There was no statistical difference (p = 0.476) in the mean operative time between the laparoscopic (52.2 min; range, 20-155) and open appendectomy (49.3 min; range, 20-110) groups. The overall incidence of minor and major complications was significantly lower (p = 0.006) after laparoscopic appendectomy (2.9%, 4 cases) than after open appendectomy (13.2%, 12 cases); rate of intra-abdominal abscess were similar. The length of hospital stay was significantly shorter (p = 0.001) in laparoscopic group (2.75 days; range, 1-8) than in open group (3.87 days; range, 1-19). The mean total cost was 2282 Euro in laparoscopic group and 2337 Euro in open group, with a no significant difference of 55 Euro (p = 0.812). CONCLUSION: Laparoscopic appendectomy is associated with fewer complications, shorter hospital stay, and similar operative time, intra-abdominal abscess rate, and total costs, compared with open appendectomy. Therefore, laparoscopic appendectomy can be recommended as preferred approach in acute appendicitis.

Surgical resection of ruptured fibrolamellar hepatocellular carcinoma.

Fibrolamellar hepatocellular carcinoma (FLH) is a rare primary tumor of the liver, which typically arises from noncirrhotic livers and affects patients below the age of 35. We report on a 29-year-old male patient who presented with a ruptured FLH and was treated with surgical resection. Options for treatment and review of the management are described.

Rare hepatic metastases of colorectal cancer in livers with symptomatic HBV and HCV hepatitis.

AIM: The liver is the most common site of metastases in colorectal cancer but metastases seem to be less common in patients with a chronically liver damage. The aim of our study was to assess the development of metachronous liver metastases in patients affected by HBV or HCV related liver diseases. MATERIAL OF STUDY: We retrospectively evaluated above all the development of liver metastases and the 5-year disease free in 457 patients radically treated for colorectal cancer with healthy liver and in 31 patients radically treated for colorectal cancer affected by liver damage (HBV or HCV related). RESULTS: Overall incidence of liver metastases was 9% (44/488), in particular 3.2% in infected patients and 9.4% in non-infected patients (p= 0.34). Our results revealed that there is no statistically significant difference between the number of positive lymph nodes of primary colorectal cancer and the number of indifferentiated cancers in infected compared with non-infected patients (29% vs 34.1% and 9.7% vs 13.6% respectively), and the 5-year disease free is better for infected patients (93% and 80%, p = 0.17). DISCUSSION: In infected patients we registered a better crude 5-year disease free interval and a fewer incidence of metachronous liver metastases. This difference is in agreement with other results mentioned in literature. CONCLUSION: In the light of the reported data, the authors consider that the recent pathogenetic theory of the "metalloproteinase inhibitor" should be taken in account.

Laparoscopic splenectomy for splenic hamartoma in elderly patien Case report and review of the literature.

AIM: We proved the feasibility and the safety of the laparoscopic splenectomy for splenic hamartoma in elderly patients. MATERIAL AND METHODS: We present the first case of laparoscopic splenectomy for splenic hamartoma in elderly patients and we reviewed the English literature regarding the laparoscopic approach. RESULTS: A 74-year-old man with a 6-month history of left upper quadrant abdominal and back pain was referred to our hospital for the evaluation of a splenic mass detected by ultrasonography. Computerized tomography scan (CT) revealed the presence of a solid tumor in the upper pole of the spleen (size 5.3 x 4.5 cm). The diagnosis of a malignant tumor was not excluded completely and because of increasing severe left upper quadrant pain, after three days the patient underwent laparoscopic splenectomy and the final pathological diagnosis was splenic hamartoma. The patient's postoperative course was uneventful and the patient was discharged by the sixth postoperative day. CONCLUSIONS: Splenectomy is still necessary for diagnostic and therapeutic purposes and mini-invasive surgical technique today represents the standard procedure for the management of any space-occupying lesions of the spleen also in elderly patients. KEY WORDS: Elderly patients, Hamartoma, Laparoscopic splenectomy, Management.

Bile duct injury during laparoscopic cholecystectomy without intraoperative cholangiography: a retrospective study on 1,100 selected patients.

BACKGROUND: Whether to routinely or selectively use intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) has been a controversial issue for many years. Many authors maintain that IOC decreases the rate of biliary complications such as bile duct injuries, biliary leak, and missed common bile duct (CBD) stones. However, in contrast to these claims, many centers have opted to perform LC without IOC. In this retrospective study, the results of a series of 1,100 LCs, all of which involved major biliary complications and which were performed without the use of IOC, were reviewed. METHODS: Data from 1,100 selected patients (728 females and 372 males) undergoing LC without the use of IOC from January 2003 to November 2011 were analyzed. One hundred and seventy LCs were performed by young surgeons during the learning curve, and 930 by surgeons with over 10 years of experience. Two techniques were used to create pneumoperitoneum: the Veress technique in 319 cases (29%) and the Hasson technique in the remaining 781 cases (71%). Patients with a suspicion of CBD stones were excluded from the study. RESULTS: Two CBD injuries (0.18%) and three biliary leaks (0.27%) were detected among this group. Thirty-three patients (3%) needed conversion to open cholecystectomy. Missed CBD stones were reported in 4 cases (0.36%). There was no postoperative mortality. CONCLUSION: LC can be performed safely without the use of IOC and with acceptable low rates of biliary complications. An accurate preoperative evaluation of clinical risk factors, precise operative procedures, and conversion to an open approach in doubtful cases are important measures which must be taken to prevent CBD injury.

Appendiceal-sigmoid fistula presenting in a man with ulcerative colitis: a case report.

INTRODUCTION: Ulcerative colitis is a chronic disease characterized by diffuse mucosal inflammation limited to the colon. It mostly affects young adults, yet a large number of middle-aged and older patients with ulcerative colitis have also been reported. CASE PRESENTATION: A 58-year-old Caucasian man presented to our hospital in August 2006 with continuous and diffuse abdominal pain, meteorism, fever and bloody diarrhea. He had a two-year history of ulcerative colitis. Our patient was treated with intravenous medical therapy. As his condition worsened, he underwent surgery. An explorative laparotomy revealed that the entire colon was distended and pus was found around an appendiceal-sigmoid fistula. CONCLUSIONS: Therapy for ulcerative colitis is a rapidly evolving field, with many new biological agents under investigation that are likely to change therapeutic strategies radically in the next decade. Indications for surgery are intractability (49%), stricture, dysplasia, toxic colitis, hemorrhage and perforation. To the best of our knowledge, this is the first case of an appendiceal-sigmoid fistula in a patient affected by ulcerative colitis reported in the literature. Fistulae between the appendix and the sigmoid tract are rarely reported in cases of diverticular disease and appendicitis.

Thyroid surgery without cut and tie: the use of Ligasure for total thyroidectomy.

Total thyroidectomy is the surgical preferred procedure for the treatment of benign and malignant disease. The purpose of this research was to evaluate total thyroidectomy operation by Ligasure in comparison with total thyroidectomy by the traditional technique that uses clamp and tie. We evaluated 256 patients. In 144 patients (56%), we used Ligasure without tie for total thyroidectomy; in the remaining 112 patients (44%), we used clamp and tie. The middle values of the variables examined were inferior (P < 0.0005) in the Ligasure group compared with the clamp and tie group. Only the middle value of operating room costs was higher in the first group than in the second, balanced by a decreased hospital stay of two days. Ligasure can be safely used for total thyroidectomy, because there is a meaningful difference in the distribution of variance between the two groups. There are decreasing risks of parathyroid gland and laryngeal nerve injury in the Ligasure group.

Biliary stent migration into the abdominal wall: a case report.

Biliary stent migration occurs in about 5% of patients. The most common complications secondary to stent migration are pancreatitis, small bowel perforation and peritonitis. We report the case of a patient presenting with an abdominal wall abscess secondary to migration of a biliary stent. Direct abdominal radiography, abdominal ultrasound and CT scan have proved very useful in the diagnosis, providing the correct localisation of the stent in the left rectus muscle of the abdominal wall that led to a surgical approach under local anaesthesia for the removal, and abscess formation surrounding the stent. The patient was discharged on the day after surgery. After reviewing the literature concerning this rare complication, the Authors conclude that closer monitoring of patients with biliary prostheses is needed to prevent the migration and the consequent serious complications.

Laparoscopic surgical treatment of perforated duodenal ulcer.

Perforation of peptic ulcer is a surgical emergency which still carries a risk of mortality. The main risk factors are delayed diagnosis > 24 hours, ASA-III or ASA-IV, age over 70 years, and associated cardiorespiratory pathologies. There is no unanimous consensus regarding the gold standard treatment of such complications. In this study we report our experience and analyse the literature with the aim of assessing the possible advantages of laparoscopic treatment of perforated duodenal ulcers versus open surgery. From April 2003 to December 2008, 39 patients underwent laparoscopic repair and 7 patients open repair of perforated duodenal ulcer. The following parameters were evaluated in all patients: operative time, duration of hospital stay, time to intestinal canalisation, morbidity and mortality. The conversion rate, in laparoscopic treated patients, was 0%. The mean operative time was longer in the laparoscopic group than in the open group (76.15 +/- 9.49 vs. 63.57 +/- 15.19 minutes; Mann Whitney test p < 0.05). The laparoscopic cases had a shorter mean hospital stay than the open cases (5.8 +/- 1.02 vs. 7.8 +/-1.34 days; Mann Whitney test p < 0.001). The time to canalisation in the two groups of patients was similar. One patient (2.56%) in the laparoscopic group and two (28.57%) in the open repair group presented morbidity in the postoperative period. One patient (ASA IV) in the open group died. Laparoscopic treatment in the emergency setting is a safe, reliable procedure, affording all the advantages of the minimally invasive approach.

Ultrasound-guided percutaneous treatment of abdominal collections.

Abdominal abscess is a very important problem nowadays, being responsible for prolonged hospitalisation, because these infections still cause substantial morbidity and mortality. For many years, surgical drainage has been considered the best therapeutic option in abdominal abscesses but several studies have subsequently shown that the percutaneous approach is as effective as surgical drainage. Starting from this background, the aim of this study was to evaluate whether or not percutaneous drainage is a valid treatment of choice. In the Department of Surgical Sciences, Organ Transplantation and Advanced Technologies of the University of Catania, 451 ultrasound guided percutaneous drainages of intra-abdominal abscesses were performed on 430 patients. Abscess drainage was successful in 322/403 (80%) of postoperative abscess, in 16/18 (90%) of primitive abscesses, in 10/12 cases (85%) of acute cholecystitis, in 3/6 cases (50%) of intrahepatic abscess and in 12/12 cases (100%) of pyelonephritis. US-guided drainage is currently the gold standard in the treatment of simple abdominal abscesses.

Laparoscopic appendectomy for acute appendicitis.

The advantages and applications of the videolaparoscopic technique (VL) versus open surgery in the treatment of acute and complicated appendicitis are not well defined. The aim of this study was to identify which of the two procedures is more suitable. The study examined 124 patients, 73 females (57.5%) and 51 males (42.5%). We compared 62 patients in the laparoscopic group with 62 open surgery patients. We analysed the results of the two groups (VL, open) for age, gender, operative time, hospital stay, complications and costs. The mean patient age was 24.1 years (range: 4-70). The conversion rate was 1.6% (1 case/62). The patients in the laparoscopic group were predominantly female (p < 0.0001). The average age of VL patients compared to open surgery was significantly higher (p < 0.01). The mean operative time was not significantly different between the two groups. The hospitalisation time was shorter for the laparoscopic group (4.77 vs. 6.39 days, p < 0.01). Complications were 0% for VL and 4.81% for the open group. The average operation cost in the open group was 8070.00 euros (+/- 4267) and 6818.00 euros (+/- 1446,00) for VL (p < 0.05). Laparoscopic appendectomy has significant advantages over traditional open surgery and should be the first choice in cases of acute but uncomplicated appendicitis.

A rare cystic non-functioning neuroendocrine pancreatic tumor with an unusual presentation.

This report describes a patient with a cystic non-functioning neuroendocrine glucagon cell pancreatic tumor presenting with demyelination of the optical nerve that had initially provoked marked monolateral reduced vision and had led to a suspected diagnosis of multiple sclerosis. Cystic degeneration is uncommon in endocrine pancreatic tumors due to their abundant vascular supply. Very few cases of cystic neuroendocrine non-functioning pancreatic tumors have been reported in the international literature. The presence of atypical neurological symptoms, such as sudden visual impairment, should be taken into account in the differential diagnosis for such tumors. The prognosis is poor, because most of these tumors are malignant and diagnosed at an advanced stage. The three-year disease-free survival of our patient, however, encourages the use of aggressive surgical treatment.