Procalcitonin, as an early biomarker of colorectal anastomotic leak, facilitates enhanced recovery after surgery.

PURPOSE: Procalcitonin (PCT) is a biomarker used to help sepsis diagnosing and monitoring and guide antibiotic therapy. Anastomotic leak (AL) after colorectal surgery is a severe complication associated with relevant short- and long-term sequelae. The aim of our study is to assess the predictive value of PCT levels to early diagnose AL after colorectal surgery. METHODS: Between September 2011 and September 2012, a series of 99 patients underwent colorectal surgery in our institution. In all cases, white blood cell (WBC) count, C-reactive protein (CRP), and PCT levels were measured in first, third, and fifth postoperative day (POD). Anastomotic leaks and all other postoperative complications were recorded. RESULTS: We registered 7 ALs (7.1%). Decreased PCT levels had a significant negative predictive value (NPV) for AL in third and fifth POD (96.7% and 96.7%, respectively), compared with CRP and WBC. The best diagnostic performance was obtained with the combination of PCT and CRP measurements in third and fifth POD (area under the curve, 0.87 and 0.94, respectively). In 5th POD, PCT improves diagnosis, but not in a statistically significant way (area under the curve, 0.86). CONCLUSIONS: Compared with more established biochemical values such as CRP and WBC, PCT is an earlier, more sensitive, and reliable marker of AL. Increased PCT levels in early PODs after colorectal surgery may provide a more effective way to detect AL, before clinical symptoms appear. Moreover, normal PCT values might be also a useful marker to facilitate a safe and early discharge of selected patients after colorectal surgery.

Radioguided surgery with combined use of gamma probe and hand-held gamma camera for treatment of papillary thyroid cancer locoregional recurrences: a preliminary study.

BACKGROUND: Persistent differentiated papillary thyroid cancer (PTC) with metastasis followed by radical locoregional surgery is an indication for limited reoperation. Despite excellent prognosis the major challenge is controlling locoregional recurrences. AIM: To evaluate the efficacy of radioguided excision with combined use of gamma probe and an hand-held gamma camera. PATIENTS AND METHODS: From June 2009 to January 2012, we enrolled twenty-two patients with locoregional PTC recurrences, previously undergone to central and/or lateral neck dissection for PTC. The diagnosis of recurrent PTC was based on thyroglobulin (TG) evaluation [basal and after thyroid stimulating hormone (TSH) stimulation], ultrasound (US), iodine-131 (131I) whole body scan (WBS) and fine needle aspiration cytology (FNAC). In the morning of surgery, radiotracer was injected directly into the lesions by US guide. Careful dissection was carried out using gamma probe and hand held gamma camera. Metastatic lymph nodes were identified and excised. RESULTS: In all the patients recruited, 39 pathologic nodes were injected and 61 nodes were removed. Among the removed nodes, 22 (36.1%) were additional nodes (not injected by radiotracer). Of the additional lymph nodes, 7 (31.8%) were metastatic. Mean radioactive count of the lesion (28.633±9.218 counts/s) was higher than tumor bed (385.73±192.23 counts/s) (p < 0.0001). No complications were observed during radioguided excision, neither on post-operative period. CONCLUSIONS: The use of hand-held gamma camera in addition to gamma probe in our preliminary study allows a minimally invasive procedure and safer identifications of the lesions and ensures the completeness of the excision in a difficult surgical field.

Renal artery embolization in a gross kidney neoplasm. Case report.

AIM: To demonstrate the utility of the renal artery embolization (RAE) in the dissection of gross neoplasms and the reduction in blood loss and operative time. CASE REPORT: We report a case of a gross left renal neoplasm (with the diameter of about 12 cm) in a 45 years old Caucasian female who underwent to renal artery embolization 24 hours before left nephroureterectomy. This procedure has determined a reduction in operative times (about 90 minutes) because of the ligature of the renal vein was facilitated. Intraoperative blood loss was of about 100 ml and the patient didn't need of blood transfusions; the abdominal drain was removed in third postoperative day (daily drained serous fluid was about 20 ml). The patient was discharged 7 days later. CONCLUSION: RAE facilitates the dissection of gross neoplasms (diameter> than 10 cm), so causing a reduction in intraoperative blood loss and in blood transfusion. The operative times are lower because the ligature of the renal vein is less difficult and the dissection is facilitated for the presence of tissue oedema. The disadvantages are the incomplete hembolyzation, coil migration, hematomes, post-infarction syndrome (nausea, vomit, abdominal pain, leucocytosis, hyperpyrexia, hematoma); other risks include the possibility of pulmonary embolism, intestinal infarction and infections. Its reduced utilization could be due to the lack of randomized prospective studies showing its potential benefits.

Multidisciplinary approach for diagnosing syncope: a retrospective study on 521 outpatients.

OBJECTIVES: To describe causes of syncope in outpatients in whom structural heart disease was ruled out as a cause, and to analyse the role of a multidisciplinary approach in a syncope unit for the diagnosis of patients with syncope of unknown origin. METHODS: Cardiovascular autonomic nervous system (ANS) function was evaluated extensively in 521 outpatients by careful history, physical examination including orthostatic blood pressure measurement and standard ECG, and tilt testing. RESULTS: Causes of syncope remained unknown in 29.2% of cases. ANS dysfunction was found in 58.6% of those presenting with either neurally mediated syncope (53.6%) or chronic autonomic failure (5%); 3.8% of the patients suffered from syncope of cardiogenic origin (2.5%) or non-neurogenic hypotension (1.3%), and 8.4% had loss of consciousness of non-syncopal origin. Loss of consciousness was confirmed as being related to seizures in under 30% of patients initially diagnosed as having epilepsy. CONCLUSIONS: Neurally mediated syncope represents the commonest type of syncope. ANS evaluation including tilt testing should be considered as preliminary screening in patients with syncope in the absence of definite heart abnormalities. Neurologists should consider syncope from ANS failure as a comorbid factor in patients with seizures where the clinical characteristics are not straightforward.

[Stromal tumors of the stomach. Review of the literature and description of a case of "uncommitted" stromal tumor]. / Tumori stromali dello stomaco. Revisione della letteratura e descrizione di un caso di tumore stromale "uncommitted".

Non-epithelial non-lymphomatous neoplasms of the gastrointestinal tract are known as stromal tumors (GISTs) because of the tissues in which they originate (4), (16). These neoplasms are rare and account for about 4% of all the tumors of the stomach. Their malignancy and biological and anatomopathological behaviour are related to clinical problems, since their histopathological picture is both complex and controversial. Modern immunohistochemical and ultrastructural (12), (26) studies have identified forms of myogenic or neural origin, which are more differentiated, as well as mixed types with both components, and types, though surely stromal, of uncertain origin, therefore called "uncommitted" (22), (25). The latter are extremely rare and, since it is not yet possible to classify them, some Authors use the term GIST only for these groups. A report of a clinical case of "uncommitted" GIST offers the opportunity to review the literature, highlighting the increased incidence of these tumors (which is probably related partially to the improved diagnostic techniques (3)), their potential malignancy and the difficulty of a correct classification and, therefore, a clear prognosis.