Outcome of acute pancreatitis in octogenarians: A retrospective study.

BACKGROUND AND AIM: Acute pancreatitis (AP) is a common disease, but data on outcomes in octogenarians are scarce in the literature. The aim of this study is to analyze results from patients aged 80 years old and over who were treated for AP at a single center. METHODS: Patients aged 80 years and older diagnosed with AP from April 2010 to October 2015 were considered. Demographics, American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), serum biochemistry at 24 and 48 h after admission, and revised Atlanta severity score were analyzed and correlated with hospital mortality rate and length of stay using the multiple regression and Kaplan-Meier tests. RESULTS: A total of 100 consecutive patients were included in the study. There were 52 women, and the mean age was 87.5 years (range 80-95). Gallstones were the most common cause of AP (69.7%). The ASA score was ≥III in 51 patients. Eight patients had severe, disease and all of them died in hospital. A CCI > 4 was associated with higher disease severity and mortality (P < 0.00001). The median hospital stay was 9 days (range 1-59). Longer hospital stay was associated with serum C-reactive protein ≥242 mg/L (P = 0.01) and serum albumin ≤30 g/L (P = 0.01) at 48 h. Over a 5-year period, 22% of patients were readmitted to hospital with recurrent AP. Gallstones were the main cause of disease (63.6%). CONCLUSIONS: AP in octogenarians has low mortality. Higher death rate is associated with disease severity. In the presence of gallstone disease, cholecystectomy is recommended whenever possible as the risk of disease recurrence is significant.

Outcome of Laparoscopic Common Bile Duct Exploration After Failed Endoscopic Retrograde Cholangiopancreatography: A Comparative Study.

Background: Common bile duct stones (CBDS) are treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) or with the single-stage laparoscopic common bile duct exploration (LCBDE) and LC. Multiple ERCP attempts and failure increase the risk of postprocedural complications. In such circumstances surgery is advocated. The aim of the study is to compare the outcome of LCBDE and LC in patients who had never had an ERCP, to that of patients who underwent previously failed ERCP. Methods: A retrospective analysis of 54 patients undergoing LCBDE and LC between 2010 and 2017, was performed. Patients were divided in 2 groups: primary surgery (group 1), surgery after failed ERCP (group 2). Demographics and preoperative investigation results were collected. Comparative outcomes were common bile duct (CBD) clearance rate, operative time, conversion to open rate, postoperative morbidity, mortality, and hospital stay. Data were evaluated with the Student's t, Chi-square, or Fisher's tests. Results were considered as statistically significant when P < .05. Results: In both groups CBD clearance was above 90%. The mean operative time was longer in group 2 (130.3 minutes ± SD 83.72 vs. 178.73 ± 57.22; P < .05). There was no difference in the conversion to open and postoperative complication rates between groups. A bile leak occurred in 2 patients from group 1, 3, from group 2. No postoperative mortality occurred. The median hospital stay was longer in group 2 (2 days ± SD 2.54 vs. 5 ± 5.77; P < .05). Conclusions: LCBDE and LC is safe and effective in patients who had previous failed ERCP. If ERCP failure is anticipated and/or the risk of post-ERCP complications is high, surgery should be considered as the first-line treatment of CBDS. Longer intraoperative time and hospital stay are expected.

Electrochemotherapy for basocellular and squamocellular head and neck cancer: preliminary experience in Day Surgery Unit.

BACKGROUND: The aim of this study was to evaluate feasibility, safety and efficacy in day surgery of electrochemotherapy (ECT) using bleomycin in non-melanoma head and neck skin cancer. METHODS: We performed a prospective study on fifteen patients treated at the General Surgery Department at University Hospital of Tor Vergata, Rome between April 2011 and February 2013. RESULTS: We observed 100% complete response evaluated with WHO criteria at 6 weeks after treatment. No partial response was achieved. CONCLUSIONS: ECT is a simple, highly effective and safe treatment for head and neck non melanoma skin cancer. In our experience ECT can be performed safely in Day Surgery also in patients ASA III. Side effects associated with ECT are minimal and the treatment is well tolerated also by older patients, with minimal impairment of organ function and healthy tissues and with good esthetic results. We would encourage this treatment especially for older patients with multiple comorbidities, in which conventional surgical approach is not easily practicable.

An Unusual Case of Primary Extranodal Lymphoma of the Gallbladder.

Primary gallbladder lymphoma is an extremely rare disease. We report a case of a 63 year-old woman who has been admitted with gradual onset abdominal pain in the upper right quadrant and in the suprapubic region, nausea and malaise. According to the computed tomography scan of the abdomen, which was suggestive of chronic cholecystitis, she was treated conservatively. A laparoscopic cholecystectomy was performed 5 months later and the histological examination of the gallbladder showed a low grade small lymphocytic lymphoma. The patient has been taken over by the hematology team who kept her under surveillance as no further treatment was deemed as necessary. The purpose of this paper is to report a rare case of primary gallbladder lymphoma and to demonstrate that a laparoscopic cholecystectomy may be a valid treatment for this disease.

Partial renal resection by LaparoNewPro: in vivo open and laparoscopic study in an animal model.

INTRODUCTION: The aim of this research project was to test an incremental bipolar radiofrequency generator with open and laparoscopic inline electrode probe for partial renal resection without vascular clamping. MATERIAL AND METHODS: Sixteen polar resections with clamping and six without were performed in four pigs in the acute phase. Three pigs underwent laparoscopic polar resection and were live housed for ten days and reoperated to verify the presence of hematic and urinary collection and the condition of the renal edge. Five pigs underwent laparoscopic polar resection without clamping, and two of these were live housed and reoperated after ten days. RESULTS: Polar renal resection by our system (LaparoNewPro) turned out to be effective and safe, without cardio-respiratory complications or damage to the remaining parenchyma. Coagulation of the renal parenchyma before resection is effective and safe; at the reoperation, no complications were observed. The laparoscopic version of the probe is ergonomic and safe, with effective coagulation and a small amount of smoke produced. No complications occurred in the housed animals. No damage, local or to residual parenchyma, or thrombosis of the renal vessels were found. CONCLUSIONS: LaparoNewPro is able to deliver coagulation of the resection line effectively and independently of clamping of the vessels both in the open and laparoscopic approaches. Coagulation times are short, the automatism of the generator is reliable, and the open and laparoscopic probes are ergonomic.

Anomalous radiological and clinical demonstration of gallbladder duplication in an asymptomatic pregnant female.

Gallbladder duplication is an uncommon congenital anatomical deviation encompassing a number of variants. The morphological difference occurs during budding of the hepatic diverticulum. We report the case of an asymptomatic pregnant woman who was incidentally found to have a large subhepatic cyst on ultrasound. The case highlights the difficulty in diagnosing large gallbladder duplication and the different radiological imaging available to surgeons to aid in mapping such anatomical variants. We propose that this case holds valuable lessons for both radiologists and surgeons when considering the differential diagnosis and management of large hepatobiliary cysts.

Cutaneous metastasis of unknown primary presenting as massive and invasive abdominal lesion: an elective approach

Abstract: We describe herein what is to our knowledge the first reported case of an invasive cutaneous metastasis with unknown primary, electively treated solely with electrochemotherapy. We describe a female patient with a large, invasive and painful lesion in her hypogastric region, extending up to the pubic area. The cutaneous biopsy and instrumental and laboratory analyses, all failed to reveal the primary site. A final diagnosis of cutaneous metastasis with unknown primary was made and treatment was performed with electrochemotherapy. Our case highlights the importance of interdisciplinary choices in clinical practice to cope with the lack of a primary site and to improve quality of life, since no standardized therapy exists for these classes of patients.

Recurrent incisional hernia, enterocutaneous fistula and loss of the substance of the abdominal wall: plastic with organic prosthesis, skin graft and VAC therapy. Clinical case.

Surgical wounds dehiscence is a serious post-operatory complication, with an incidence between 0.4% and 3.5%. Mortality is more than 45%. Complex wounds treatment may require a multidisciplinary management. VAC Therapy could be an alternative treatment regarding complex wound. VAC therapy has been recently introduced on skin's graft tissue management reducing skin graft rejection. The use of biological prosthesis has been tested in a contaminated field, better than synthetic meshes, which often need to be removed. The Permacol is more resistant to degradation by proteases due to its cross-links. Surgery is still considered the best treatment for digestive fistula. A 58 years old obese woman come to our attention, she was operated for an abdominal hernia. She had a post-operatory entero-cutaneous fistula. She was submitted to bowel resection, the anastomosis has been tailored and the hernia of the abdominal wall has been repaired with biological mesh for managing such condition. She had a wound dehiscence with loss of substance and the exposure of the biological prosthesis, nearly 20 cm diameter. She was treated first with antibiotic therapy and simple medications. In addiction, antibiotic therapy was necessary late associated to 7 months with advanced medications allowed a small reduction's defect. Because of its, treatment went on for two more months using VAC therapy. Antibiotic's therapy was finally suspended. The VAC therapy allowed the reduction of the gap, between skin and subcutaneous tissue, and the defect's size preparing a suitable ground for the skin graft. The graft, managed with the vac therapy, was necessary to complete the healing process.

Cancer of the sigmoid colon and antibodies. A puzzle.

UNLABELLED: In this work we describe the case report of a woman affected by cancer of the sigmoid colon and with a positive direct antiglobulin test (DAT) and indirect antiglobulin test (IAT). Case report with results: A meticulous medical history showed that the woman had been suffering from recurrent fetal loss. Then she had cardiac and coagulative problems. These data suggested a phospholipid syndrome. CONCLUSION: The patient had a medical history positive for a phospholipid syndrome and we think that this disease could explain the onset of the autoantibody.

Cutaneous metastasis of unknown primary presenting as massive and invasive abdominal lesion: an elective approach with electrochemotherapy.

We describe herein what is to our knowledge the first reported case of an invasive cutaneous metastasis with unknown primary, electively treated solely with electrochemotherapy. We describe a female patient with a large, invasive and painful lesion in her hypogastric region, extending up to the pubic area. The cutaneous biopsy and instrumental and laboratory analyses, all failed to reveal the primary site. A final diagnosis of cutaneous metastasis with unknown primary was made and treatment was performed with electrochemotherapy. Our case highlights the importance of interdisciplinary choices in clinical practice to cope with the lack of a primary site and to improve quality of life, since no standardized therapy exists for these classes of patients.

Novel and effective balanced intravenous-inhalant anaesthetic protocol in swine by using unrestricted drugs.

Nowadays, because of increasing employment of swine for experimental studies and medical training, it is hopeful to investigate novel and effective anaesthetic protocols for preserving the animal welfare in medical investigation and concurrently improving the quality of research. Therefore, the aim of this study was to investigate a novel and effective anaesthetic protocol in swine undergoing major surgery, by translating know-how of combined anaesthesia from human protocols. Seven landrace swine were anaesthetized for three hours by a combined trial anaesthetic protocol (sedation: medetomidine, acepromazine, atropine and tramadol; induction: propofol, medetomidine and acepromazine; anaesthesia: isofluorane, propofol, medetomidine and acepromazine) and both clinical and haemodynamic parameters were compared with those of five swine anaesthetized with a control protocol (sedation: diazepam, ketamine and atropina; induction: diazepam and ketamine; anaesthesia: isofluorane). Both cardiac frequency (CF) and mean blood pressure (MBP) were significantly (P<0.05) more stable in trial protocol (CF: 78.3 ± 4.6-81.1 ± 5, MBP: 63.9 ± 10.7-96.4 ± 13.0) compared to control protocol (CF: 93.7 ± 5.5-102.5 ± 8.5, MBP: 71.0 ± 6.6-108.7 ± 7.2). The body temperature remained stable in trial protocol (°C: 36.9 ± 0.7-37.2 ± 0.3) compared to control anaesthesia (°C: 36.4 ± 0.3-37.3 ± 0.2, P<0.05). Haematosis improved undergoing combined anaesthesia (+2%, P<0.05) whereas did not change in control animals. There were no differences in respiratory rate between trial and control protocols. This study demonstrates that the proposed balanced intravenous-inhalant protocol permits to carry out a very effective, stable and safe anaesthesia in swine undergoing deep anaesthesia.

Gradual colonic impaction of a chicken bone associated with inflammatory pseudotumor formation and nonocclusive colon ischemia.

Foreign body (FB) ingestion is a common clinical problem and most FBs pass through the gastrointestinal tract without the need for intervention. A wide spectrum of clinical presentations may be possible and these can be either acute or chronic. We present a case of an 83-year-old woman featuring insidious abdominal discomfort who was hospitalized in our institution due to worsening symptoms. She underwent contrast-enhanced computed tomography (CT) evaluation which showed the presence of a significant parietal thickening of the transverse and descending colon, a mesenteric loose tissue imbibition, venous engorgement, and no filling defect of visceral arteries, suggesting a condition of nonocclusive colon ischemia. A hyperdense FB was identified in the sigma and was associated with a small pseudotumoral mass. The patient underwent surgical exploration which confirmed the hypoperfusional state of the colon, showing the presence of a chicken bone perforating the sigma and lying in the context of a pseudotumoral mass. Our experience shows how contrast-enhanced CT is feasible and can be strongly recommended as a first-line imaging tool on suspicion of colon ischemia and also how it can easily identify the underlying cause, in our case a FB sealed perforation of the sigma with pseudotumoral mass formation.

Partial nephrectomy using radiofrequency incremental bipolar generator with multi electrode probe: experimental study in bench pig kidneys.

BACKGROUND: The aim of this research project was the realization of an incremental bipolar radiofrequency generator with inline 4-electrode probe for partial renal resection without clamping of the vessels. METHODS: The experimentation was carried out across two phases: the preliminary realization of a specific generator and an inline multielectrode probe for open surgery (Phase 1); system testing on 27 bench kidneys for a total of 47 partial resection (Phase 2). The parameters evaluated were: power level, generator automatisms, parenchymal coagulation times, needle caliber, thickness of the coagulated tissue "slice", charring, ergonomy, feasibility of the application of "bolster" stitches. RESULTS: The analysis of the results referred to the homogeneity and thickness of coagulation, energy supply times with reference to the power level and caliber of the needles. The optimal results were obtained by using needles of 1.5 mm caliber at power level 5, and with coagulation times of 54 seconds for the first insertion and 30 seconds for the second. CONCLUSIONS: The experimentation demonstrated that the apparatus, consisting of a generator named "LaparoNewPro" and fitted with a dedicated probe for open surgery, is able to carry out a coagulation of the line of resection of the renal parenchyma in a homogeneous manner, in short times, without tissue charring, and with the possibility of stitching both on coagulated tissue and the caliceal system. The generator automatism based on the flow of the current supplied by each electrode is reliable, and the cessation of energy supply coincides with optimal coagulation.

Inflammatory fibroid polyp. A case report and review of the literature.

INTRODUCTION: The Inflammatory fibroid polyp (IFP) is a mesenchymal polypoid lesion of the gastrointestinal tract that follows a benign course. Incidence is extremely low: from 0,1% to 2 %. Histologically, it consists of a sub mucous proliferation of vascolarized fibromuscolar tissue with a high eosinophils inflammatory infiltration. IFP can arise everywhere in the gastrointestinal tract but is described more frequently in the gastric antrum (70%). CASE REPORT: We report a case of a 71-year-old woman presented to our department with a worsening history of lack's appetite, nausea and early satiety. We performed a review of the literature from 1949 to 2011. 196 cases of IFPs were found. CONCLUSION: Clinical symptoms are heterogeneous and endoscopy's examination revealed only presence of a sub-mucosal lesion, and their biopsies often gave not diagnostic localization. In the differential diagnosis, it's important to discern between eosinophilic gastroenteritis, gastrointestinal stromal tumor, inflammatory pseudotumor, hemangioendothelioma, and hemangiopericytoma. Eco-endoscopic appearance and biopsies associated may provide useful informations, that can steer to the diagnostic suspect of IFP. Despite this is a benign lesion, this one often needs a surgical excision on healthy margin. In literature is also described high local recurrence, specially when incomplete excision proceeded. KEYWORDS: Gastric sub-mucosal tumor, Inflammatory fibroid polyp, Stomach, Vanek's Tumor.

Use of intraoperative endoscopy to localize bleeding in the small intestine.

INTRODUCTION: Bleeding within the small intestine is difficult to diagnose and localize because it typically occurs at a slow rate. These patients may undergo multiple transfusions and repeated endoscopy, contrast studies, bleeding scans, and angiography before the bleeding source is identified. CASE REPORT: We report a case of 64-year-old woman, where both endoscopic and angiographic techniques were used to localize protracted bleeding. During endoscopic treatment, the arteriovenous malformations continued bleeding. However, highly selective angiography and intraoperative endoscopy outlined the segments of small intestine for resection. This case reviews the evaluation, localization and treatment of small intestine bleeding. DISCUSSION: Localizing the site of protracted bleeding in the small intestine beyond the duodenum bulb can be problematic. For some patients, the course of examinations and transfusions can take years. The small intestine is an uncommon site for gastrointestinal hemorrhage, and only 3%-5% of gastrointestinal bleeding occurs between the ligament of Treitz and the ileocecal valve. The length and location of the small intestine, along with other anatomical factors, make this area difficult to assess with endoscopy or radiology. In this case of protracted bleeding, highly selective angiography and intraoperative endoscopy were used to locate the source of the bleeding.

Solitary skin metastasis from sarcomatoid carcinoma of the bladder: a case report.

INTRODUCTION: Cutaneous metastases from carcinomas of the bladder are very rare. They are related to advanced stages of the disease and have poor prognosis with low survival rates. The common treatment modality of cutaneous metastases from a primary bladder cancer is wide local excision followed by chemotherapy. CASE PRESENTATION: We report a case of solitary skin metastasis from a rare type of urinary bladder carcinoma in a 68 year-old Caucasian man. Urinary bladder carcinoma metastasizing to the skin is an uncommon finding despite the high incidence of this tumor. Skin metastasis generally presents in the late stages of this disease and indicates a poor outcome. CONCLUSIONS: Because of the extremely aggressive malignant potential of sarcomatoid carcinomas, the indications for a transurethral resection of the bladder should be carefully assessed and suitable therapeutic strategies should be examined further.

[Bodypackers syndrome. A case report and review of the literature]. / La sindrome "body packers". Caso clinico e revisione della letteratura.

INTRODUCTION: With the term Body packers we identify people who carry drugs hidden in their bodies especially on international flights. These event are constantly increasing all over the world. The accidental spontaneous opening of the drug packers is the major risk for patient's life, because the release cocaine inside the bowel can stir up the Body packers Syndrome. This eventuality is a medical surgical emergency that needs a wel timed diagnosis and a sudden treatment. CASE REPORT: We report a case of a 31 years old Caucasian woman, admitted from Rome International Airport to the nearest Emergency Unit and then moved to our Department because of suspected epilepsy hiding a diagnosis of Body packers Syndrome in acute phase. When the diagnosis was made, the woman was submitted to a colonoscopy and ciecotomy, and fifty-three packets were removed. In intensive care any complication occurred after surgery. CONCLUSION: The Body packing of drugs it's constantly a going problem. In Italy currently there aren't shared guide lines about the management of these patients. The international experience reports that in asymptomatic patients is enough a conservative treatment to help the spontaneous evacuation of packets but if the Body packers Syndrome is already present the best treatment is the surgical one. Quickness, accuracy and right use of radiology are the main factors to reach a correct diagnosis and to obtain a good result.

Spontaneous intraperitoneal rupture of pyonephrosis in a patient with unknown kidney carcinosarcoma: a case report.

Seventeen cases of peritonitis due to rupture of a pyonephrosis have been reported. The majority of these cases occur secondary to renal stones. Only two cases of ruptured pyonephrosis with concurrent kidney neoplasm have been described and only one of these presented as an acute peritonitis. In this presentation we discuss an unusual case of a 68 year old man with a chronic history of bilateral nephrolithiasis and recent pyonephrosis. He presented acutely with peritonitis and was later found to have a carcinosarcoma of the kidney. The case highlights the importance of recognizing the possibility of underling renal carcinoma in patients presenting with a ruptured pyonephrosis and discuss steps to avoid this serious complication.