HOSPITAL ADMISSION, MEDICAL, AND SURGICAL PROCEDURES FOR ACUTE DIVERTICULITIS ARE MORE APPROPRIATE WHEN USING A DIAGNOSTIC AND THERAPEUTIC ASSISTANCE PATHWAY: AN EXPERIENCE FROM A REFERRAL CENTRE.

IIntroduction: Our aim was to assess the impact of the Diagnostic and Therapeutic Assistance Pathway (PDTA) developed for acute diverticulitis (AD) on the management of patients with AD and referring to the emergency Room (ER) in a referral centre. METHODS: This retrospective study includes all patients diagnosed with AD and referring to the ER between January 1st 2021 and December 31st 2022 (after approval of PDTA), compared to the same period of 2015-2019. Length of stay in ER, medical and surgical management, and lenght in hospital stay (in days) were also measured according to the type of disease (uncomplicated vs. complicated). RESULTS: ER admission due to AD during the period 2015-2019 was 240±13 cases per year, while it was 290 cases in 2022 (p=0.05). After adopting the PDTA, the rate of lenght of stay in ER >24h for AD was significantly reduced (p=0.01); the median rate of hospital admission for AD was significantly reduced (p<0.05); the rate of medical treatment of uncomplicated disease was increased (p=0.01), while the rate of surgical management was decreased (p=0.05); the rate of medical treatment of complicated disease was increased (p=0.01), while the rate of surgical management was decreased (p=0.001); the hospital stay was significantly reduced both in uncomplicated (p=0.05) and uncomplicated (p=0.05) AD. CONCLUSIONS: The development and the routinely use of a PDTA dedicated to AD has significantly improved the management of these patients, reducing the ER stay, the surgical procedures and the overall hospital stay.

Pragmatic computerised perfusion diagnostics for non-convulsive status epilepticus: a prospective observational study.

BACKGROUND: Non-convulsive status epilepticus (NCSE) is a time-dependent neurological disorder often misdiagnosed in the emergency setting. Electroencephalography (EEG) is often not available on a 24/7 basis, and Salzburg criteria may at times miss the diagnosis. Here, we tested the accuracy of hyperperfusion on CT perfusion imaging (CTP) in the identification of NCSE against Salzburg criteria, to define its potential role in a pragmatic diagnostic workflow. METHODS: We enrolled consecutive patients with suspected acute seizure or seizure disorder undergoing brain imaging with CTP and EEG from January 2021 to March 2023. EEG recordings, Salzburg criteria and CTP hyperperfusion were rated and adjudicated by two independent experts blinded to patient status. A reference standard including all clinical, lab, imaging, EEG and therapeutic data was used to adjudicate NCSE diagnosis. Sensitivity, specificity, diagnostic accuracy, positive and negative predictive values (NPV) were calculated for CTP hyperperfusion and Salzburg criteria versus NCSE adjudicated according to reference standard. RESULTS: Seventy-seven patients were enrolled. Among 21 NCSE cases, 17 were adjudicated according to Salzburg criteria (81%) and 4 received NCSE diagnosis according to reference standard. Agreement between EEG and CTP emerged in 16/21 NCSE cases, reaching sublobar level in 37.5% of cases. Receiver operator curve analysis suggested good accuracy for CTP hyperperfusion for the diagnosis of NCSE (AUROC 0.79, 95% CI 0.69 to 0.89). CTP hyperperfusion had a high NPV for NCSE (NPV 0.97, 95% CI 0.86 to 1). CONCLUSION: CTP hyperperfusion may be implemented in the emergency fast-track to rule out NCSE, given very high NPV. Further validation studies are needed to evaluate CTP application in real-world setting for NCSE codes.

Predictors of postoperative hospital length of stay after total knee arthroplasty.

INTRODUCTION: To collect and analyse clinical and functional variables of patients undergoing rehabilitation after total knee arthroplasty (TKA), in order to identify which amongst them could influence the post-operative length of hospital stay (LOS). METHODS: We conducted a retrospective analysis of prospectively collected data of 1,082 consecutive patients (746 females and 336 males) who underwent primary TKA and rehabilitation in our Orthopedic Institute between January 2013 and July 2017. Clinical and anthropometric data were analysed using a multivariate linear regression model. RESULTS: The average LOS was 5.08 ± 2.52 days in the Department of Orthopedic Surgery, and 12.67 ± 5.54 days in the Rehabilitation Unit. Age, female sex and the presence of comorbidities were predictive of a longer stay. The presence of caregiver assistance at home was associated with shorter LOS. There was no evidence of a statistically significant positive association between BMI and LOS. CONCLUSION: An in-depth and early knowledge of these factors may enable the whole multidisciplinary team to plan a patient-tailored rehabilitation path and a better allocation of resources to maximize patients' functional recovery, while reducing LOS and the overall cost of the procedure.

Sclerosing angiomatoid nodular transformation (SANT) of spleen mimicking a splenic abscess: Case report and review of the literature.

INTRODUCTION: SANT of the spleen is a benign lesion that does not recur after splenectomy with unknown etiology. PRESENTATION OF THE CASE: We report a case of sclerosing angiomatoid nodular transformation (SANT) of the spleen mimicking a splenic abscess in a patient with imaging studies that failed to differentiate this lesion from other splenic lesions. DISCUSSION: SANT of the spleen is a rare condition, with only less than 100 cases reported in the literature. Clinically, SANT is only a kind of described pathological diagnostic conception. As in our case, these splenic lesions are often incidental findings on imaging studies performed for other reasons. CONCLUSION: The patient was treated with splenectomy, which has proved to be both diagnostic and therapeutic. Although histology can lead to the diagnosis of vascular tumor, immunohistochemistry is the only way to confirm the diagnosis.

Endovascular treatment of ruptured pancreaticoduodenal artery aneurysm: The importance of collateral vessels. A case report.

INTRODUCTION: True pancreaticoduodenal artery aneurysm occurrence is infrequent, but it is a fatal disease and accounts for accounts for <2% of all visceral aneurysms. PRESENTATION OF CASE: A 62-year-old man with a two-day history of epigastric pain was admitted at emergency department. CT showed a retroperitoneal haematoma due to a 1.5cm posterior inferior PDA ruptured aneurysm. Angiography had been conducted immediately: both inflow and outflow of the aneurysm were embolized. Another CT scan had been conducted, which revealed residual flow inside the aneurysm sac fed by small collateral vessels. Sub-selective catheterization was repeated and definitive haemostasis was obtained by embolizing the collateral vessels. Postoperative course was uneventful. CT scan follow-up at 36 months showed no abnormalities. DISCUSSION: The incidence rate of pancreaticoduodenal artery aneurysm rupture has been estimated to be less than or equal to 65%. In the case of rupture the treatment is challenging and mortality had been reported up to 50%. Endovascular treatment showed superior results as compared to surgical treatment of aneurysms, especially in emergency settings. CONCLUSION: The authors elucidate the importance of occlusion of inflow and outflow of the aneurysm in conjunction with the occlusion of collateral vessels to avert reperfusion of the sac. Simultaneous handling of celiac axis stenosis is still prone to controversy: no relapse of aneurysm have been reported in patients with celiac axis stenosis at long-term follow-up, simultaneous treatment should be reserved when angiography is alarming for likely hepatic or duodenal ischemia.

THY3 cytology: What surgical treatment? Retrospective study and literature review.

INTRODUCTION: THY3 nodules collects 20% of cytological examinations, with a rate of malignancy by about 20-30%, and represent one of the most controversial topics of scientific debate. In fact, differential diagnosis of follicular lesions, is very difficult, due to the inability of cytology to differentiate between adenomas and carcinomas. Surgery represents the only possible diagnostic and therapeutic approach, but on the type of surgery there is still absolute discordance of opinions. METHODS: We retrospectively analyzed 230 patients undergoing total thyroidectomy for THY3 cytology between May 2007 and September 2013. Subsequently we re-evaluated our results assuming a conservative surgical approach in patients without preoperative contralateral pathological evidence. RESULTS AND DISCUSSION: Our results indicate an incidence of malignancy in THY3 cytology of 29.6% (n = 68/230), in line with literature data; multifocal bilateral carcinoma in 26.5% of patients; 37 incidental carcinomas (16.5%), 15 of which located contralateral at THY3 nodule; nodular hyperplasia in 52.2% of patients. So, according to a conservative surgery, among patients ideally underwent lobectomy (n = 110), we wouldn't recognize 10 of overall 105 malignancies (9.5%) (including bilateral tumors on THY3 and contralateral incidental carcinomas). Thus, these malignancies would be neither diagnosed nor removed during surgery. CONCLUSIONS: We believe these results allow to state that total thyroidectomy is oncologically the most appropriate intervention to make the patient "disease-free". Moreover, our study could serve as a motivation for further research, but maybe is needed a new Consensus Conference to define a surgical protocol universally recognized.

Liver abscess and pseudotumoral gastric lesion caused by chicken bone perforation: laparoscopic management.

The accidental ingestion of a foreign body into the gastrointestinal tract is not uncommon, but the vast majority of foreign bodies pass through the gastrointestinal tract uneventfully within a week. Less than 1% of patients with foreign body ingestion develop complications such as perforation of the gastrointestinal tract. The migration of an ingested foreign body may result in chronic inflammation, a silent clinical course, and radiological features suggestive of a neoplasm. The authors report a case of chicken bone perforation of the gastric wall that leads to hepatic abscess formation and thereafter to submucosal pseudotumor of the gastric wall treated with totally laparoscopic management. Usefulness of endoscopic ultrasonography for a correct diagnosis is also stressed.

Parathyroid carcinoma: the importance of high clinical suspicion for a correct management.

Background. Parathyroid carcinoma is an infrequent clinical entity whose diagnosis is very challenge. Indeed a pre-operative or intraoperative diagnosis of parathyroid carcinoma is reported in less than half cases described in the literature. Patients and Methods. A systematic review of pathological reports of our secondary referral hospital was done. From 2003 to 2011 one hundred and forty-four patients were operated for hyperparathyroidism. One patient with atypical adenoma and three patients with parathyroid carcinoma were included in this paper. Results. An en bloc resection of the tumor was performed in three patients. Two of this patients with diagnosis of parathyroid carcinoma are alive with no evidence of recurrence or metastasis, respectively, 48 and 60 months after the operation; one patient with diagnosis of atypical adenoma died for other disease 16 months after the operation. In the last patient a simple parathyroidectomy was performed. After that histology revealed the diagnosis of parathyroid carcinoma the patient underwent reoperation for left hemithyroidectomy and central compartment lymph node clearance. After 30 months a lung lobectomy was done due to metastasis. Conclusion. Parathyroid carcinoma should be considered in the differential diagnosis of PTH-dependent hypercalcemia because optional outcomes are associated with complete resection of the tumor at the time of initial operation.

Comparison of two extracorporeal shock wave therapy techniques for the treatment of painful subcalcaneal spur. A randomized controlled study.

OBJECTIVE: To describe and compare two extracorporeal shock wave therapy techniques for the treatment of painful subcalcaneal spur. DESIGN: Random assignment to two groups of treatment with two and eight months follow-up. SETTING: The data were collected in outpatients. SUBJECTS: Forty-five subjects with a history of at least six months of heel pain were studied. INTERVENTIONS: Each subject received a three-session ultrasound-guided extracorporeal shock wave therapy (performed weekly). Perpendicular technique was used in group A (n=22, mean age 59.3 +/- 12 years) and tangential technique was used in group B (n= 23, mean age 58.8 +/- 12.3 years). MAIN OUTCOME MEASURES: Mayo Clinical Scoring System was used to evaluate each subject before the treatment and at two and eight months follow-up. RESULTS: Mayo Clinical Scoring System pretreatment scores were homogeneous between the groups (group A 55.2 +/-18.7; group B 53.5 +/- 20; P>0.05). In both groups there was a significant (P<0.05) increase in the Mayo Clinical Scoring System score at two months (group A 83.9 +/- 13.7; group B 80 +/- 15,8) and eight months (group A 90 +/- 10.5; group B 90.2 +/-8.7) follow-up. No significant differences were obtained comparing the Mayo Clinical Scoring System scores of the two groups at two and eight months follow-up. CONCLUSIONS: There was no difference between the two techniques of using extracorporeal shock wave therapy. The tangential technique was found to be better tolerated as regards treatment-induced pain, allowing higher energy dosages to be used.

Acute emphysematous cholecystitis as a cause of pneumoperitoneum.

The authors report a rare case of acute emphysematous cholecystitis with pneumoperitoneum. Emphysematous cholecystitis is an uncommon variant of acute cholecystitis. Association with pneumoperitoneum is very rare and the finding of a macroscopic perforation of the gallbladder is possible only in a few cases. A review of the literature revealed 15 other cases of this combination. Diagnostic options and treatment modalities in these patients are discussed here.

Perforated jejuneal diverticulosis. Case report and review of literature.

Acquired (non-Meckel's) jejunoileal diverticulosis is an uncommon disease, generally characterised by vague and unspecific symptoms. This rare condition is mainly expressed as acute complications: gastrointestinal haemorrhage, mechanic obstruction of the small intestine or perforated diverticulum, requiring urgent surgical intervention. The authors report a case of this unusual clinical occurrence characterized by a picture of abdominal pain due to perforation of jejuneal diverticulum. The final etiological diagnosis was possible only during surgery.

Iatrogenic intramural hematoma of the duodenum caused by endoscopic therapy of bleeding peptic ulcer. A case report.

The authors report a case of intestinal obstruction resulting from a duodenal intramural hematoma after therapeutic upper digestive endoscopy with injection therapy. Intramural duodenal hematomas are rare clinical entities, mostly caused by blunt traumas. They may also, more rarely, be due to complications of peptic duodenal ulcers, or be the iatrogenic result of an endoscopic biopsy or placement of a percutaneous endoscopic gastrostomy catheter. It has recently become obvious that surgery is not necessary in most patients with duodenal hematomas. The treatment of choice for cases of intramural duodenal hematomas is of a conservative kind. Today we can employ minimally invasive diagnostic and therapeutic techniques for the percutaneous or laparoscopic evacuation of the hematoma, which seem to guarantee optimal results, compared to the high morbidity rate associated with laparatomy evacuation.

Comparison among preoperative single-slice CT and multi-slice CT in simple, closed loop and strangulating bowel obstruction.

BACKGROUND/AIMS: The aim of this study is to compare preoperative single-slice CT (SSCT) and multislice-CT (MSCT) accuracy in the evaluation of patients with bowel obstruction and intestinal necrosis. METHODOLOGY: 64 patients were enrolled. We analyzed the SSCT scans of 30 patients and the MSCT scans of 34 patients with clinical and abdominal plain film evidence of bowel obstruction. Presence, site, kind, and cause of the obstruction were evaluated; specific signs of strangulating or closed loop obstruction and wall necrosis were also identified. Three radiologists interpreted the CT scans independently; a consensus review was obtained, indicating the need of emergency or delayed surgery. The results were assayed on the basis of surgical findings. RESULTS: SSCT and MSCT findings of bowel obstruction presented good correlation with the surgical report. Sensitivity, specificity, PPV and NPV were 86.1%; 89.3%; 91.1%; and 83.3% respectively. The k coefficient of interobserver agreement was significant (0.729; p<0.01). A major difference was observed between findings in SSCT and MSCT in detecting intestinal ischemia (p <0.05); a noteworthy statistical difference between these techniques was observed especially in the sensitivity and specificity of the edema, twisting and/or thickening of mesenteric vessels (p<0.05). CONCLUSIONS: The first objective of abdominal CT in patients with bowel obstruction is to evaluate the need for emergency surgery because delayed operations potentially result in high mortality. A CT presenting high correlation to surgical findings allows a correct surgical timing and planning thanks to the correct identification of site, kind, and causes of bowel obstruction. MSCT presents better results compared to SSCT in assessing intestinal necrosis.

[Thyroid surgery: total and partial resection. Analysis of complications and a review of the literature]. / La chirurgia tiroidea: exeresi totale ed exeresi parziale. Analisi in termini di complicanze e revisione della letteratura.

The authors review the recent international literature relating to approximately 36,800 cases of thyroid surgery, analysing the complications associated with total thyroidectomy versus partial resection of the thyroid, with a view to drawing up lines of conduct in terms of indications for surgery of benign disease and suggestions on surgical technique to reduce complications such as recurrent laryngeal nerve injuries (transient and definitive), hypocalcaemia (transient and definitive) and superior laryngeal nerve injuries.

[Classification and management of gynecologic acute abdomen at a secondary level hospital emergency department]. / Inquadramento e gestione dell'addome acuto di origine ginecologica in un Dipartimento di Emergenza ed Accettazione di II livello. Analisi di 103 casi.

This study retrospectively evaluates the preoperative work-up and the classification and operative treatment of acute abdomen caused by gynaecological disorders in emergency admissions to our department. All female patients admitted in the emergency setting and operated on for gynaecological acute abdomen in our emergency department over the period from 1997 to 2002 were included in the study. A total of 103 patients were identified (54 undergoing emergency operations, 9 operated on within 72 hours, and 40 managed conservatively with medical therapy. The 54 emergency operations performed were 24 ovarian resections, 17 salpingectomies, 5 oophorectomies, 4 exploratory laparotomies, 2 uterine polypectomies and 2 hysterectomies. The non-specific presentation of the disease and an inadequate preoperative work-up in these patients often led to a generic diagnosis at admission. This approach tends to increase the number of operations performed on an emergency basis, whereas a wait-and-see type of management should be adopted. A proper use of surgery is mandatory especially in those patients in whom preservation of reproductive capability has a major impact on outcome.