Early diagnosis of anastomotic leakage after colorectal surgery by the Dutch leakage score, serum procalcitonin and serum C-reactive protein: study protocol of a prospective multicentre observational study by the Italian ColoRectal Anastomotic Leakage (iC.

BACKGROUND: Anastomotic leakage (AL) is a dreaded major complication after colorectal surgery. There is no uniform definition of anastomotic dehiscence and leak. Over the years many risk factors have been identified (distance of anastomosis from anal verge, gender, BMI, ASA score) but none of these allows an early diagnosis of AL. The DUtch LeaKage (DULK) score, C reactive protein (CRP) and procalcitonin (PCT) have been identified as early predictors for anastomotic leakage starting from postoperative day (POD) 2-3. The study was designed to prospectively evaluate AL rates after colorectal resections, in order to give a definite answer to the need for clear risk factors, and testing the diagnostic yeld of DULK score and of laboratory markers. Methods and analysis. A prospective enrollment for all patients undergoing elective colorectal surgery with anastomosis carried out from September 2017 to September 2018 in 19 Italian surgical centers. OUTCOME MEASURES: preoperative risk factors of anastomotic leakage; operative parameters; leukocyte count, serum CRP, serum PCT and DULK score assessment on POD 2 and 3. Primary endpoint is AL; secondary endpoints are minor and major complications according to Clavien-Dindo classification; morbidity and mortality rates; readmission and reoperation rates, length of postoperative hospital stay (Retrospectively registered at ClinicalTrials.gov Identifier: NCT03560180, on June 18, 2018). Ethics. The ethics committee of the "Comitato Etico Regionale delle Marche - C.E.R.M." reviewed and approved this study protocol on September 7, 2017 (protocol no. 2017-0244-AS). All the participating centers submitted the protocol and obtained authorization from the local Institutional Review Board.

Does the nasogastric tube has a role in elective colo-rectal surgery?

INTRODUCTION: Routine use of nasogastric tubes (NGT) after abdominal operations is intended to hasten the return of bowel function, diminish the risk of anastomotic leakage and prevent pulmonary complications. The aim of our study was to prospectively assess the tolerability and the safety of the non use of NGT after elective colorectal open operations. PATIENTS AND METHODS: Between March 2009 and December 2010, 110 consecutive patients underwent colo-rectal elective open surgery for neoplasm without nasogastric decompression. We analyzed the incidence of nausea and vomiting, the pulmonary complications, the return of bowel function the deep wound breakdown (fascial dehiscence) and the anastomotic leakage. RESULTS: Only 15 patients (13,6%) reported nausea without vomiting immediately after surgery and 9 cases of vomiting were observed (8%), requiring the insertion of the NGT (nasogastric tube) in 5 (4,5%). A total of 105 patients (96,3%) were NGT free. No deep wound dehiscence was observed and only one real pneumonia occurred. Anastomotic dehiscence occurred in 4 patients (3,6%) and a second surgical procedure was needed in three cases. The return of bowel function, except in the last four patients, occurred in 3,8 days average (range 2-7 days). CONCLUSION: We confirm the uselessness of the NGT in the framework of fast track program adopted in elective open colo-rectal surgery.

[Experience of a peripheral center in the surgical treatment of hepatic metastasis from colorectal cancer]. / Esperienza di un centro periferico nel trattamento chirurgico delle metastasi epatiche da cancro colorettale.

Surgical resection is still the first therapeutic option in patients with resectable colorectal cancer metastatic to the liver. Application of radiofrequency energy has been used in patients who did not meet the criteria for resectability and yet were candidates for a liver-directed procedure based upon the presence of liver-only disease. Hepatic resection has evolved in the last two or three decades from a procedure with associated mortality rate of up to 20% in the early 80s to usually less than 5% in patients undergoing liver resection thereafter. This improvement in morbidity and mortality is multifactorial; despite the increased safety of liver operations, hepatic resection still remains a complex surgical procedure with serious potential morbidity. The experience with liver resections and/or radiofrequency ablations, for colorectal cancer metastatic to the liver, performed at a medium-volume center (15 cases in 4 years) is presented. Some features of the metastatic disease, including the number, size and location of metastases are identified. The perioperative mortality is 0, morbidity for non surgical complications is 40%. In this series the reported overall 1-yr survival is 80%, 2-yr is 67%. This paper reviews the experienced factors that have defined the morbidity and mortality associated with liver surgery.

Minimally invasive treatment of giant CSF pseudocyst complicating ventriculoperitoneal shunt.

A two-liter cerebrospinal fluid pseudocyst complicating a ventriculoperitoneal shunt was drained and a distal catheter retrieved from the peritoneal cavity by laparoscopy. Adoption of such a minimally invasive approach allowed the prompt resolution of the complication and an early recovery for out patient.

[Rare neoplasms of the pancreas: the papillary-cystic tumor. A report of 2 cases]. / Neoplasie rare del pancreas: il tumore papillare-cistico. Osservazioni a proposito di due casi.

The authors report two cases of papillary-cystic tumor of the pancreas in two young women. Making a review of literature, they emphasize the rarity of this neoplasm and analyze the possible histopathologic origin, the difficult diagnosis before surgery, surgical therapy and the good prognosis of this pancreatic "curable" tumor.

[Prognostic factors in acute mesenteric ischemia. Experience of 64 cases]. / Fattori prognostici nell'ischemia mesenterica acuta. Esperienza di 64 casi.

A retrospective study of 64 cases of acute mesenteric ischaemia is reported. The patients have been treated, during the past 12 years, at the Department of Surgery "Flaiani", Ospedale San Camillo de Lellis-Rome. In terms of favourable prognosis, the following factors have shown to be statistically significant: enteric resection carried out, thrombosis of superior mesenteric vein, preoperative normal BUN and WBC count. The diagnostic value of CPK-BB is emphasized as well as the prognostic significance of a prompt surgical treatment.

[Compression of the celiac trunk by the median arcuate ligament]. / Compression du tronc coeliaque par ligament arqué au diaphragme.

A relatively large series of 20 operated patients, aged 28 to 66 years, with median arcuate ligament syndrome is presented. There has been a change in the pattern of presentation of this condition in recent years. Early diagnosis can now be made with greater frequency than previously. The origin and the symptoms due to the intermittent, chronic abdominal ischaemia are discussed. The preliminary results suggest that surgical decompression is effective in inducing favourable changes in 60% of patients.

[Surgical treatment of hyperlipidemia by partial ileal by-pass]. / Traitement chirurgical de certaines hyperlipidémies par court-circuit iléal partiel.

This study is composed of 7 hyperlipidaemic patients (type II, n = 4; type IV, n = 3), aged 33 to 59 years. These patients underwent a partial ileal by-pass, and the immediate post-operative period was uneventful. Six months post-operatively, serum levels of cholesterol and triglycerides were 45 and 44% of the pre-operative values. Serum electrolytes remained unchanged as well as liver function tests. In the first few days post-operatively, diarrhoea was a frequent complaint; by the 6th post-operative month, the stools numbered 2-3 per day in patients not receiving any medical treatment. Average weight loss was 6 +/- 1.3%. These preliminary results may confirm that partial ileal by-pass produces favourable metabolic changes. However, screening for late complications is to be further investigated, and the effectiveness of the operative procedure must still be evaluated.

[Is functional demand a condition without which the pancreatic auto transplant can not survive in the dog's spleen?]. / La demande fonctionnelle est-elle une condition sine qua non à la survie de tissus pancréatiques autotransplantés dans la rate chez le chien?

Two groups of mongrel dogs underwent intrasplenic autotransplantation of pancreatic tissues prepared from the head and tail of the organ. In the first group (12), the operation was terminated by the removal of the rest of the gland. In the second group (8), total pancreatectomy was done 6-8 months after autotransplantation. The first group of dogs became spontaneously normoglycemic after ten days of moderate hyperglycemia; their insulinemia increased significantly during a glucose loading test. The second group of dogs never became normoglycemic but remained vivacious; insulin level in their splenic vein increased moderately only after glucose injection. Microscopically, exo- and endocrine pancreatic tissues were seen in the spleens of the first group of dogs; in the spleens of the second group of dogs, only a few degenerating B cells were observed. These results suggest that the temporary hyperglycemia following autotransplantation of pancreatic tissues is a functional demand: it is necessary for ultimate survival and function of transplanted B cells.

[Role of the bile in lesions of the intestinal mucosa above a mechanical occlusion]. / Rôle de la bile dans l'apparition des lésions de la muqueuse intestinale lors d'une occlusion mécanique.

In dogs, the principal lesion in the ileal mucosa above a mechanical obstruction is the induction of a secretory state in which there is a net loss of water and electrolytes into the intestinal lumen. The role of stagnated bile as a possible agent provoking this secretion was explored by ligating the common bile duct and diverting the bile by means of an anastomosis between the gall bladder and the ileum distal to the obstruction. Seven days after creation of an obstruction with bile derivation, the functional and morphological changes in the obstructed loop were almost identical to those occurring in animals with obstructions without bile diversion. The secretory response above the obstruction continued unabated. These results suggest that the secretion in the obstructed intestine is not influeced by the presence of bile.