Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma (SICUT) guidelines

Dealing with acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients is frequent during daily practice and requires complex management. Several procedures exist to postpone and/or prevent surgical intervention in those patients who temporarily or definitively cannot undergo surgery. After a systematic review of the literature, an expert panel from the Italian Society of Emergency Surgery and Trauma (SICUT) discussed the different issues and statements in subsequent rounds. The final version of the statements was discussed during the annual meeting in Rome (September 2022). The present paper presents the definitive conclusions of the discussion. Fifteen statements based on the literature evidence were provided. The statements gave precise indications regarding the decisional process and the management of patients who cannot temporarily or definitively undergo cholecystectomy for acute cholecystitis. Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients should be multidisciplinary. The different gallbladder drainage methods must be tailored according to each patient and based on the expertise of the hospital. Percutaneous gallbladder drainage is recommended as the first choice as a bridge to surgery or in severely physiologically deranged patients. Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative especially as a definitive procedure for those patients not amenable to surgical management. Trans-papillary gallbladder drainage is the last option to be reserved only to those unfit for other techniques. Delayed laparoscopic cholecystectomy in patients with percutaneous gallbladder drainage is suggested in all those patients recovering from the conditions that previously discouraged surgical intervention after at least 6 weeks from the gallbladder drainage.

Intestinal Ischemia: Unusual but Fearsome Complication of COVID-19 Infection

The pathophysiology of gastrointestinal damage in coronavirus disease (COVID-19) is probably multifactorial. It is not clear whether the etiology of intestinal ischemia may be directly related to viral replication or may result from hyper-coagulability following SARS-CoV-2 infection.To confirm a pathogenic role of COVID-19, we retrospectively investigated the presence of SARS-CoV-2 virus in the ischemic bowel of five COVID-19 patients undergoing emergency surgery for intestinal ischemia in the period of March 2020-May 2021. Immunohistochemical positivity with weak intensity was observed in four out of five cases, but only one case was strongly positive both at immunohistochemistry and at molecular analysis. The histological alterations in the intestinal tissue samples showed similarity with the well-known alterations described in typical targetorgans of the virus (e.g., the lung). This observation suggests a similar mechanism of action of the virus. Further larger studies are, thus, required to confirm this preliminary finding. Clinicians should carefully monitor all COVID-19 patients for the possible presence of a SARS-CoV-2 intestinal infection, a potential cause of ischemia and bowel perforation.

Indocyanine Green (ICG) for the assessment of splenic perfusion during laparoscopic splenic artery aneurysmectomy. A case report

CASE REPORT

We describe the case of a 54-year-old man with a 20mm splenic aneurysm, who underwent laparoscopic aneurysmectomy, without splenic removal. The residual splenic blood supply was assessed by using indocyanine green i.v. administration.

CLINICAL FINDINGS

The patient presented at ED with abdominal pain, syncopal episode, and tachycardia. A CT scan with contrast showed hemoperitoneum with a 20mm splenic aneurysm, which was located at the bifurcation of the splenic and left gastroepiploic artery. Treatment and Outcome Laparoscopic surgery was then warranted. Abdominal exploration revealed a serohemorrhagic collection without active source of bleeding. After opening the gastro-colic ligament and obtaining vascular control of the splenic artery, the aneurysm was clipped and resected. No macroscopic modifications occurred to the spleen. This finding was confirmed by intravenous administration of indocyanine green. The operating time was 265 minutes. During the postoperative course, a grade A pancreatic fistula occurred. The patient was discharged on postoperative day seventh.

CLINICAL RELEVANCE

The management of true splenic artery aneurysms should be patient-tailored, considering the location of the aneurysm, operative risks and the patient's age, life expectancy and clinical status. The use of ICG in splenic surgery helps delineate the splenic parenchyma and evaluate residual splenic vascularization.

KEY WORDS

Indocyanine Green, Laparoscopy, Mini-invasive Surgery, Splenic Artery Aneurysm.

Damage control surgery for perforated diverticulitis with diffuse peritonitis: saves lives and reduces ostomy

Introduction

Over the last decade, damage control surgery (DCS) has been emerging as a feasible alternative for the management of patients with abdominal infection and sepsis. So far, there is no consensus about the role of DCS for acute perforated diverticulitis. In this study, we present the outcome of a multi-institutional series of patients presenting with Hinchey's grade III and IV diverticulitis managed by DCS.

Methods

All the participating centers were tertiary referral hospitals. A total of 34 patients with perforated diverticulitis treated with DCS during the period 2011–2017 were included in the study. During the first laparotomy, a limited resection of the diseased segment was performed followed by lavage and use of negative pressure wound therapy (NPWT). After 24/48 h of resuscitation, patients returned to the operating room for a second look. Mortality, morbidity, and restoration of bowel continuity were the primary outcomes of the study.

Results

There were 15 males (44%) and 19 females (56%) with a mean age of 66.9 years (SD ± 12.7). Mean BMI was 28.42 kg/m² (SD ± 3.33). Thirteen cases (38%) were Wasvary’s modified Hinchey's stage III, and 21 cases (62%) Hinchey's stage IV. Mean Mannheim Peritonitis Index (MPI) was 25.12 (SD ± 6.28). In 22 patients (65%), ASA score was ≥ grade III. Twenty-four patients (71%) had restoration of bowel continuity, while 10 (29%) patients had an end colostomy (Hartmann’s procedure). Three of these patients received a temporary loop ileostomy. One patient had an anastomotic leak. Mortality rate was 12%. Mean length of hospital stay was 21.9 days. At multivariate analysis, male gender (p = 0.010) and MPI (p = 0.034) correlated with a high percentage of Hartmann’s procedures.

Conclusion

DCS is a feasible procedure for patients with generalized peritonitis secondary to perforated diverticulitis, and it appears to be related to a higher rate of bowel reconstruction. Due to the open abdomen, stay in ICU with prolonged mechanical ventilation is required, but these aggressive measures may be needed by most patients undergoing surgery for perforated diverticulitis, whatever the procedure is done.

A delayed conversion may increase the risk of major complications in acute cholecystitis approached laparoscopically. A retrospective comparative cohort study

AIM

Aim of this study was to evaluate whether timing of laparoscopy lasting longer than two hours before converting to open surgery can worsen the postoperative course during laparoscopic cholecystectomy (LC) for acute cholecystitis (AC).

MATERIALS AND METHODS

Medical records of 1,161 patients who underwent urgent laparoscopic cholecystectomy for AC during the period 2001-2017 were retrospectively analyzed. A conversion to open surgery was performed in 70 (6%) patients. Among these, two groups of patients were identified: group 1 (n=51; 73%) included patients who underwent laparotomy within 2 hours from the beginning of the operation, and group 2 (n=19; 27%) included patients who underwent conversion to open surgery after more than 2 hours of laparoscopy. Patients were analyzed for demographic data and comorbidities. Major outcome measures were mortality, morbidity and length of stay. A p value < 0.05 was considered significant.

RESULTS

Reasons for conversion to open surgery included severe inflammation (46%), visceral adhesions (27%), inability to manage common bile duct stones (17%), intolerance to pneumoperitoneum (7%) and the presence of a cholecystoduodenal fistula (1%). By comparing these groups, no significant differences were noted regarding overall morbidity (29% vs 42%, p=0.31), mortality (2% vs 5%, p=0.46) and mean postoperative length of stay (8.7 vs 8.2 days, p=0.75). Major postoperative complications (grade III-V according to Clavien and Dindo classification) were significantly more frequent in group 2 (p=0.03).

CONCLUSIONS

When approaching AC laparoscopically, the decision to convert to open surgery within two hours may prevent the occurrence of major postoperative complications. Early conversion does not seem to affect the mortality and length of hospital stay.

KEY WORDS

Acute Cholecystitis, Conversion, Laparoscopy.

Open abdomen and entero-atmospheric fistulae: An interim analysis from the International Register of Open Abdomen (IROA)

INTRODUCTION

No definitive data describing associations between cases of Open Abdomen (OA) and Entero-atmospheric fistulae (EAF) exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) thus analyzed the International Register of Open Abdomen (IROA) to assess this question.

MATERIAL AND METHODS

A prospective analysis of adult patients enrolled in the IROA.

RESULTS

Among 649 adult patients with OA 58 (8.9%) developed EAF. Indications for OA were peritonitis (51.2%) and traumatic-injury (16.8%). The most frequently utilized temporary abdominal closure techniques were Commercial-NPWT (46.8%) and Bogotà-bag (21.9%). Mean OA days were 7.9 ± 18.22. Overall mortality rate was 29.7%, with EAF having no impact on mortality. Multivariate analysis associated cancer (p = 0.018), days of OA (p = 0.003) and time to provision-of-nutrition (p = 0.016) with EAF occurrence.

CONCLUSION

Entero-atmospheric fistulas are influenced by the duration of open abdomen treatment and by the nutritional status of the patient. Peritonitis, intestinal anastomosis, negative pressure and oral or enteral nutrition were not risk factors for EAF during OA treatment.

Less is more: an outcome assessment of patients operated for gallstone ileus without fistula treatment

•

In this study, 1.9% patients were diagnosed with gallstone ileus among those admitted for small bowel obstruction.

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85% of them underwent a conservative surgical approach mainly consisting in the enterolithotomy.

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Only one complication exceeded grade II in each group and no deaths were reported.

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Mean follow-up was 50 months and only one patient without fistula treatment had recurrent disease; no gallbladder cancer were identified.

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Enterolithotomy without fistula closure proved to be safe and effective for the management of gallstone ileus both on a short and long-term basis.

Background

The treatment of gallstone ileus (GI) consists of surgical removal of the impacted bilestone with or without cholecystectomy and repair of the biliodigestive fistula. The objective of this study was to assess whether sparing patients a definitive biliary procedure adversely influenced the outcome.

Materials and methods

Patients with a diagnosis of GI were reviewed. Two groups were identified: patients who underwent a definitive biliary procedure with relieving the intestinal obstruction (group 1/G1) and those who did not have a definitive biliary procedure (group 2/G2). In G2, patients were evaluated on long-term follow-up for the risk of recurrent GI disease, cholecystitis, cholangitis and gallbladder cancer.

Results

Among 1075 patients admitted for small bowel obstruction, 20 (1.9%) were diagnosed with gallstone ileus. 3 (15%) of these belong to G1, 17 (85%) to G2. The overall postoperative morbidity rate was 35% (7/20) with one complication exceeding grade II in each group. No deaths were reported. Mean follow-up was 50 months. During follow-up, one of G2 patients had recurrent disease. No biliary tract infections or gallbladder cancer were identified.

Conclusion

Enterolithotomy without fistula closure is confirmed to be safe and effective for the management of gallstone ileus both on a short- and long-term basis.

Acute appendicitis complicating De Garengeot's hernia treated with combined laparoscopic-open technique: a case series and literature review

An acute appendicitis in the context of a De Garengeot's hernia is a very rare event and represents a hard challenge for surgeons. As only few cases have been reported in literature, there is no consensus about its optimal surgical strategy of treatment. Here we present two consecutive cases of female patients presenting an uncommon acute appendicitis in a femoral hernia treated with a combined laparoscopic/open technique.

KEY WORDS

Acute appendicitis, De Garengeot's hernia, Laparoscopy.

Acute abdomen caused by greater omentum torsion: A case report and review of the literature

Torsion of the greater omentum is a rare cause of acute abdomen. Based on etiopathogenesis, it can be classified as primary or secondary. However, regardless of the cause, segmentary or diffuse omental necrosis will follow. Preoperative diagnosis is not easy, though abdominal ultrasound and computed tomography (CT) scans may show peculiar features suggestive of omental torsion. Laparoscopic resection of the affected omentum is the treatment of choice. Presently reported was a case of primary omental torsion, in addition to a comprehensive literature review.

IROA: International Register of Open Abdomen, preliminary results

Background

No definitive data about open abdomen (OA) epidemiology and outcomes exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) promoted the International Register of Open Abdomen (IROA).

Methods

A prospective observational cohort study including patients with an OA treatment. Data were recorded on a web platform (Clinical Registers®) through a dedicated website: www.clinicalregisters.org.

Results

Four hundred two patients enrolled. Adult patients: 369 patients; Mean age: 57.39±18.37; 56% male; Mean BMI: 36±5.6. OA indication: Peritonitis (48.7%), Trauma (20.5%), Vascular Emergencies/Hemorrhage (9.4%), Ischemia (9.1%), Pancreatitis (4.2%),Post-operative abdominal-compartment-syndrome (3.9%), Others (4.2%). The most adopted Temporary-abdominal-closure systems were the commercial negative pressure ones (44.2%). During OA 38% of patients had complications; among them 10.5% had fistula. Definitive closure: 82.8%; Mortality during treatment: 17.2%. Mean duration of OA: 5.39(±4.83) days; Mean number of dressing changes: 0.88(±0.88). After-closure complications: (49.5%) and Mortality: (9%). No significant associations among TACT, indications, mortality, complications and fistula. A linear correlationexists between days of OA and complications (Pearson linear correlation = 0.326 p<0.0001) and with the fistula development (Pearson = 0.146 p= 0.016).

Pediatric patients: 33 patients. Mean age: 5.91±(3.68) years; 60% male. Mortality: 3.4%; Complications: 44.8%; Fistula: 3.4%. Mean duration of OA: 3.22(±3.09) days.

Conclusion

Temporary abdominal closure is reliable and safe. The different techniques account for different results according to the different indications. In peritonitis commercial negative pressure temporary closure seems to improve results. In trauma skin-closure and Bogotà-bag seem to improve results.

Trial registration

ClinicalTrials.gov NCT02382770

Hemoptysis caused by pulmonary sequestration in perforated appendicitis: A rare case report

Pulmonary sequestration is a rare and usually asymptomatic congenital anomaly. Optimal management of this condition is still a subject of debate, including superiority of surgical resection or angiographic embolization of the aberrant arterial vessel. Presently described is rare case of a 51-year-old male who presented with hemoptysis related to pulmonary sequestration associated with acute right lower quadrant abdominal pain caused by perforated appendicitis.

Early cholecystectomy for non-severe acute gallstone pancreatitis: easier said than done

BACKGROUND

Laparoscopic cholecystectomy (LC) carried out within 3 days after an attack of non-severe acute gallstone pancreatitis (NSAGP) is recommended to reduce hospital stay and overall costs. Aim of the study was to evaluate factors that may delay a timely surgical management of NSAGP and the consequences of this deviation.

METHODS

We reviewed the charts of patients admitted for NSAGP and managed by LC during the last 14 years. A total number of 316 patients entered the study, 98 of whom underwent early LC. A comparison of pre-operative and outcome data from the group of patients undergone early LC and those who received a delayed LC (>3 days since the admission) was made.

RESULTS

Only 31% of patients presenting with NSAGP were managed by early LC. Respect to these, patients who received a delayed LC were significantly older and had a greater occurrence of clinical signs suggesting common bile duct stones (CBDS). Stabilization of co-morbidities and need to investigate preoperatively the common duct were the main factors associated to the surgical delay. By comparing patients undergone early LC and those who received delayed LC, differences regarding conversion to open surgery (2% vs. 1.3%), need to explore the common bile duct (18.3% vs. 25.6%), CBDS clearance rates (94.4% vs. 94.6%), morbidity (8.1% vs. 8.7%), and postoperative hospital stay (3.9 vs. 3.2 days) were however statistically not significant.

CONCLUSIONS

Several reasons could delay the 3-day recommendation for surgery in NSAGP. These include the need to achieve before surgery the control of age-related co morbidities, and the workup to investigate for common duct stones. A fast track program aiming to early surgery would be advisable for patients presenting with NSAGP. Compared to delayed LC, early LC appears to shorten overall hospitalization but it does not seem to have any clinical impact on the course.

An unusual case of repeated splenectomy: traumatic rupture of an accessory spleen in a previously splenectomized patient

The traumatic rupture of an accessory spleen is a very rare condition and only few cases have been reported in the literature. We describe the case of a 51-year-old man undergone splenectomy for trauma several years before, who developed hemoperitoneum due to a laceration of a voluminous accessory spleen, following an accidental two-meter fall. As a conservative management of the injury was not possible, an accessory splenectomy was then required. Thus, a briefly review of the literature about this uncommon topic was perfomed.

KEY WORDS

Accessory spleen, Laparotomy, Trauma.

Incidental appendectomy? Microscopy tells another story: A retrospective cohort study in patients presenting acute right lower quadrant abdominal pain

BACKGROUND

Optimal management of macroscopically normal appendix encountered during laparoscopy for acute abdominal pain is still unclear.

METHODS

164 acute abdominal pain cases in which laparoscopy showed a normal appendix were reviewed. No other intra-peritoneal acute disease was present in 50 patients (Group 1) whereas a miscellanea of intra-peritoneal conditions was identified in the other 114 (Group 2). All the patients underwent appendectomy with specimen examination.

RESULTS

Following incidental appendectomy significant microscopical changes were seen in 125 specimens (76%). Among these, inflammation was found in 122 and neuroendocrine tumors in 3. Appendices harbored pathological changes in n = 45 patients (90%) of Group 1 and in n = 34 patients (70%) of Group 2 patients (p < 0.05). Morbidity for incidental appendectomy was 2%.

CONCLUSION

This study supports an appendectomy in patients who are undergoing laparoscopy for acute right lower quadrant abdominal pain even when the appendix appears normal on visual inspection.

Pancreatoduodenectomy for groove pancreatitis Report of two cases

Groove pancreatitis is a rare condition with patients having clinical characteristics similar to those of chronic pancreatitis. Differentiating on clinical and radiological basis between groove pancreatitis and paraduodenal head cancer can be extremely challenging. Due to diagnostic uncertainty and to poor response to medical treatment surgery may offer these patients the best chance of cure. As the main localization of the inflammatory process is at the groove between the duodenum and the head of the pancreas, pancreato-duodenectomy is proposed as the most reliable surgical procedure. We report about two patients presenting with clinical and radiological features suggesting a groove pancreatitis in which control of symptoms was achieved by pancreatoduodenectomy.

KEY WORDS

Groove pancreatitis, Paraduodenal pancreatic cancer.

Splenic abscess after splenic blunt injury angioembolization

INTRODUCTION

Splenic Angioembolization (SAE), during Nonoperative Management (NOM) of Blunt Splenic Injury (BSI), is an effective therapy for hemodynamically stable patients with grade III, IV, and V OIS splenic injuries. We report a case of a patient with a blunt abdominal trauma due to an accidental fall, who presented splenic abscess a week after SAE and a review of the literature.

CASE REPORT

A 38-year-old male arrived at Emergency after an accidental fall with contusion of the left upper quadrant of the abdomen. Abdominal CT scan revealed the fracture of the lower splenic pole with intraparenchymal pseudoaneurysms (OIS spleen injury scale IV). Considering the hemodynamic stability, NOM was undertaken and SAE was performed. After a week, the patient developed a splenic abscess confirmed by Abdominal CT; therefore, splenectomy was performed. There was no evidence of bacterial growing in the perisplenic hematoma cultures but the histological examination showed multiple abscess and hemorrhagic areas in the spleen.

DISCUSSION

Splenic abscess after SAE during NOM of BSI is a rare major complication. The most frequently cultured organisms include Clostridium perfringens, Alpha-Hemoliticus Streptococcus, gram-positive Staphylococcus, gram-negative Salmonella, Candida, and Aspergillus. This case represents our first reported splenic abscess after SAE.

CONCLUSION

SAE is a very useful tool for BSI managing; splenic abscess can occur in a short time, even if it is a rare major complication, so it may be useful to monitor patients undergoing SAE, focusing not only on the hemodynamic parameters but also on the inflammatory and infectious aspects.

The role of laparoscopy in adult bowel obstruction caused by intussusception

AIM

The intestinal intussusception in the adult represent 1% of all occlusions. Organic causes are detectable in 90% of cases. Aim of this study is to discuss the diagnostic and therapeutic iter of adult intestinal intussusception with particular emphasis on role of laparoscopy.

MATERIALS AND METHODS

We retrospectively considered 10 cases of intussusception between January 2000 and January 2013, demographic and clinical issue, location of invagination, the type of surgical treatment, the post-operative morbidity and mortality and histological nature of occlusion cause.

RESULTS

Ten (F: M 1.5:1) patients were admitted in emergency with bowel obstruction, the median age was 50 years (r.18-91). All required surgical treatment. Three patients (30%) underwent a totally laparoscopic procedure, four patients (40%) laparoscopic exploration followed by laparotomy, three patients (30%) open surgery directly. The invagination was ileo-ileal (50%), ileo-colonic (40%) and colo-colonic (10%). Nine out of ten underwent to surgical resection. The malignancy was the most frequent cause.

DISCUSSION

In case of colonic intussusception should not be performed any reduction because the frequent association with neoplastic disease. The laparoscopy can be safe and effective to allow, in entero-enteric and entero-colic intussusception, the definitive treatment of the occlusion. In the case of colo-colonic intussusception laparoscopy is a valuable diagnostic aid and can facilitate the later processing.

CONCLUSION

The intestinal invaginations diagnosis can often be difficult. Laparoscopy is safe and effective in the diagnosis and treatment of adult intussusception.

Laparoscopic repair of perforated peptic ulcer: single-center results

BACKGROUND

Perforated peptic ulcer (PPU), the most common indication for emergency gastric surgery, is associated with high morbidity and mortality rates. Outcomes might be improved by performing this procedure laparoscopically, but no consensus exists on whether the benefits of laparoscopic repair (LR) of PPU outweigh the disadvantages.

METHODS

From January 2002 to December 2012, 111 patients underwent surgery for perforated ulcer. A "laparoscopy-first" policy was attempted and then applied for 56 patients. The exclusion criteria for LR ruled out patients who had shock at admission, severe cardiorespiratory comorbidities, or a history of supramesocolic surgery. The aim of this study was a retrospective analysis of the 56 patients treated laparoscopically.

RESULTS

The patient distribution was 30 men and 26 women, who had a mean age of 59 years (range 19-95 years). The mean ulcer size was 10 mm, and the Mannheim peritonitis index (MPI) was 21. LR was performed for 39 (69.6%) of the 56 patients and included peritoneal lavage, suturing of the perforation, and omental patching. Conversion to laparotomy was necessary in 17 cases (30.4%). The "conversion group" showed significant differences in ulcer size (larger ulcers: 1.9 vs. 0.7 mm; p < 0.01), ulcer-site topography (higher incidence of posterior ulcers: 5 vs. 0; p < 0.01), and MPI score (higher score: 24 vs. 20; p < 0.05). The LR group had a mean operating time of 86 min (range 50-125 min), an in-hospital morbidity rate of 7.6 %, a mortality rate of 2.5%, and a mean hospital stay of 6.7 days (range 5-12 days). None of these patients required reintervention.

CONCLUSIONS

The results showed that LR for PPU is feasible with acceptable mortality and morbidity rates. Skill in laparoscopic abdominal emergencies is required. Perforations 1.5 cm or larger, posterior duodenal ulcers, and an MPI higher than 25 should be considered the main risk factors for conversion.

Mesoappendix and appendix stump treatment in laparoscopic appendectomy: a retrospective study in 1084 patients

BACKGROUND

Laparoscopic appendicectomy (LA) rapresents a standard but questionable approach in the treatment of acute appendicitis. The scope of this study is to show our experience using different methods in the mesoappendix and appendix stump treatment.

MATERIALS AND METHODS

A retrospective analysis of all patient with acute appendicitis that underwent to LA was obtained. The results have been analysed compareing the single techniques used in the treatment of mesoappendix and appendix stump.

RESULTS

The study included 1084 patients (M=648; F=436; mean age 28,4 years). During laparoscopic procedure we have founded in 296 cases a CAA (27.3%). The rate of conversion to open has resulted 3,2%; the mean operative time was 57,1'; mean postoperative stay was 2,7 days. Eighteen patients have experienced surgical complications. From our data, in the treatment of mesoappendix (Clip =863, bipolar coagulation = 165, stapler = 22) and the appendix stump (endoloop =784; stapler = 265) we found no statistically difference about postoperative stay, and incidence of IAA; the operative time was longer (54,2 vs 66' p<0.05) when the surgeon prefered stapling the appendix stump; but in this group there was a higher incidence of CAA (35.2 % vs 18.7%).

CONCLUSIONS

Laparoscopic appendicectomy is safe and effective. We judge that there isn't a better technique than others but various options that should be evaluated taking care about costs, the experience of the surgeon and the degree of inflammation of the appendix.

[Outcome of laparotomy for severe secondary peritonitis]

BACKGROUND

Temporary abdominal closure with planned re-operations is a treatment method for several critical abdominal conditions. Aim of the study was to evaluate the effectiveness of laparostomy and the risk factors for survival in patients presenting with severe secondary peritonitis (SSP).

METHODS

52 patients (mean age 66.5) with a SSP were analyzed. The peritonitis developed spontaneously (n=34) or complicated a recent surgical operation (n=18). 18 patients were operated on for a bowel cancer and 6 of them had a metastatic disease. Skin closure (n=21), bogota bag (n=16) and vacuum-pack (n=15) were the methods employed to achieve temporary abdominal closure for planned re-operations. The severity of the disease was calculated by using APACHE II and Mannheim Peritonitis Index (MPI) scoring systems. Survival was the main outcome measure.

RESULTS

Mortality was 38% (n=20). Age, sex, pathogenesis of the peritonitis, type of temporary abdominal closure, number of re-operations and occurrence of entero-atmospheric fistula did not differ significantly between survivors and nonsurvivors. APACHE II (19.6 vs. 14.3; p=. 0015) and MPI (35.5 vs. 27.8; p=. 001) scores were significantly greater in the non-survivors group. The occurrence of perforated left colon/rectum was also significantly greater among non-survivors. By multivariate analysis only MPI resulted to be a significant independent risk factor for survival (p < 0.05).

CONCLUSIONS

SSP is a life-threatening condition. Laparostomy may have a role in controlling the source of abdominal infection but even with this outmost invasive surgical measure, mortality still remains high. For these patients, MPI may have a role as outcome predictor.

Uncommon cause of acute abdomen: volvulus of gallbladder with necrosis. Case report and review of literature

Gallbladder volvulus is a rare condition which can mimic an acute cholecystitis. This condition is characterized from a rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. Preoperative diagnosis is difficult. This is an acute surgical emergency that must be treated with immediate detorsion and cholecystectomy. We report a case of acute gallbladder torsion in an elderly man and review the clinical aspects of the disease in the context of the available literature.

Gastrointestinal stromal tumour of the duodenum in childhood: a rare case report

Background

Gastrointestinal stromal tumours (GISTs) are uncommon primary mesenchymal tumours of the gastrointestinal tract mostly observed in the adults. Duodenal GISTs are relatively rare in adults and it should be regarded as exceptional in childhood. In young patients duodenal GISTs may be a source of potentially lethal haemorrhage and this adds diagnostic and therapeutic dilemmas to the concern about the long-term outcome.

Case presentation

A 14-year-old boy was referred to our hospital with severe anaemia due to recurrent episodes of upper gastrointestinal haemorrhage. Endoscopy, small bowel series, scintigraphy and video capsule endoscopy previously done elsewhere were negative. Shortly after the admission, the patient underwent emergency surgery for severe recurrence of the bleeding. At surgery, a 4 cm solid mass arising from the wall of the fourth portion of the duodenum was identified. The invasion and the erosion of the duodenal mucosa was confirmed by intra-operative pushed duodenoscopy. The mass was resected by a full-thickness duodenal wall excision with adequate grossly free margins. Immunohistochemical analysis of the specimen revealed to be positive for CD117 (c-KIT protein) consistent with a diagnosis of GIST. The number of mitoses was < 5/50 HPF. Mutational analysis for c-KIT/PDGFRA tyrosine kinase receptor genes resulted in a wildtype pattern. The patient had an uneventful course and he has remained disease-free during two years of follow-up.

Conclusion

Duodenal GISTs in children are very rare and may present with massive bleeding. Cure can be achieved by complete surgical resection, but even in the low-aggressive tumours the long-term outcome may be unpredictable.

[Simultaneous laparoscopic treatment for common bile duct stones associated with acute cholecystitis. Results of a prospective study]

Laparoscopy for the management of acute cholecystitis has gained wide acceptance. Although it is well known that acute cholecystitis may be complicated by common bile duct stones in up to 15% of cases, to date there are no published studies addressing the management of common bile duct stones detected during laparoscopy for acute cholecystitis. We postulated that, when found, common bile duct stones associated with acute cholecystitis could be effectively and safety managed during the same laparoscopic procedure. We report on a five-year prospective study (2001-2005) involving 313 unselected patients who presented with a clinical diagnosis of acute cholecystitis (confirmed by specimen examination) and without any contraindication to laparoscopy. At surgery, transcystic cholangiograms were obtained in 289 (92%); the other 24 were excluded from the study. With an established diagnosis of common bile duct stones, attempts were made to clear the common bile duct by transcystic basket retrieval, ERCP or choledochotomy. Prevalence of common bile duct stones in acute cholecystitis, success of laparoscopic common duct clearance, conversion rate, operative time, morbidity, and postoperative hospital stay were the main outcome measures. Common bile duct stones were found in 63 pts (21.7%) presenting with acute cholecystitis. At laparoscopy, 12 patients (19%) required conversion to open surgery, 3 of these being due to failure to achieve common bile duct clearance. Common bile duct stones were cleared entirely laparoscopically in 51 patients (81%) by means of transcystic stone retrieval (38 pts, 75%), ERCP (12 pts, 23%) or choledocotomy (1 pt, 2%). At intention to treat analysis, patients undergoing cholecystectomy plus common bile duct clearance compared to those undergoing cholecystectomy alone, spent significantly more time in the operating theatre (mean 192 min vs 118 min, p < 0.001), needed open conversion more frequently (19% vs 6.1%, p = 0.0045), and had a higher overall morbidity rate (17.4% vs 4.4%, p = 0.015). The simultaneous procedure also adversely affected the postoperative hospital stay (mean 4.8 vs 3.4 days, p = 0.0164). Mortality was nil in both groups. The prevalence of common bile duct stones in patients presenting with acute cholecystitis should not be neglected. When common bile duct stones are found, clearance may be obtained laparoscopically in a substantial number of cases without any need for open surgery. The simultaneous laparoscopic approach for acute cholecystitis and common bile duct stones remains, however, a highly skilled and technically demanding procedure. Although a moderate incidence of drawbacks is observed, the results should be interpreted from the point of view of an all-in-one procedure that allows the patients to be cured without needing any further sequential interventions.

Giant epidermoid cyst of the spleen with carbohydrate and cancer antigen production managed laparoscopically

True cysts of the spleen are rare; in a few cases, high serum levels of carbohydrate and cancer antigen have been reported. In such instances, cyst resection or splenectomy is indicated to rule out malignant lesions and to remove the cancer antigen producing epithelium. We report the case of a young woman with a symptomatic giant epidermoid cyst of the spleen. Due to the secreting epithelium lining the cyst, serum levels of CA 19-9 and CA 125 were elevated. Laparoscopic splenectomy achieved symptoms relief and and long-term normalization of serum tumor markers.

Percutaneous management of multiple bilateral liver abscesses complicating Crohn disease

Liver abscess is a rare complication of Crohn disease. A case of multiple, bilateral, pyogenic liver abscesses appearing as a recurrent manifestation of Crohn disease in a 34-year-old man is reported. Conservative management with antibiotics, double-catheter drainage, and multiple aspirations was successful. The liver abscesses disappeared with no recurrence during a 5-year follow-up period.

Effect of blood transfusions on disease-free interval after rectal cancer surgery

BACKGROUND/AIMS

To assess retrospectively the impact of perioperative blood transfusions on disease-free interval after curative surgery of rectal cancer.

METHODOLOGY

One hundred and seven (107) subjects (65 men and 42 women, median age: 67) underwent anterior resection of the rectum for rectal cancer between 1990 and 1996. Thirty-six (37%) were transfused perioperatively. Outcome variables measured were: age, sex, distance of the tumor from the anal verge, type of stapled anastomosis, protective colostomy, cancer-free margin in the specimen, grading and staging, leak of the suture line, transfusion, number of blood units given, and adjuvant therapy.

RESULTS

Transfusion, nodes involvement and adjuvant therapy had a significant impact on disease-free interval at the univariate analysis. The estimated probability of cancer-free survival at 5 years was 81% for the not transfused, and 63% for the transfused patients (P < 0.05). At multivariate analysis, nodes involvement resulted significantly and independently related to time to recurrence (P < 0.05) but also perioperative blood transfusion showed an important role as independent risk factor for rectal cancer relapse (P = 0.05).

CONCLUSIONS

This study suggests that blood transfusion is likely to have a detrimental effect on disease-free interval after resective surgery of rectal cancer.

Laparoscopic treatment of appendico-cecal intussusception

Laparoscopy is a therapeutic possibility in pediatric surgery. A case of appendiceal intussusception treated laparoscopically in a 27-month-old girl is presented. The postoperative course was normal.

Laparoendoscopic treatment of gastric ectopic pancreas

A case of ectopic pancreas located on the anterior gastric wall treated with a combined gastroscopic and laparoscopic approach, which permitted isolation and complete resection of the lesion, is reported. The patient was discharged without complication.

[Echography in the surgical emergency]

Abdominal sonography represents the diagnostic method of choice in case of acute abdomen. On the bases of their experience on more than 1200 consecutive examinations performed in case of acute abdomen the author evaluate the fields of application of sonography in acute patients. A decisional algorithm in trauma patients based on sonographic results is presented. The actual indications of sonography abdominal non traumatic pathology are presented: paying particular attention to acute gastro-intestinal diseases. The therapeutic role of interventional sonography in the acute abdomen is also discussed.

[Intestinal reconstruction after a Hartmann intervention: a high-risk procedure?]

BACKGROUND/AIM

Restoration of the bowel continuity after Hartmann's procedure has been reported to carry a high rate of both general and anastomosis-related complications. Aim of the study was to test the hypothesis of the Hartmann's procedure reversal as high-risk surgery. STUDY DESIGN, SETTING: Retrospective analysis of a cases series, University hospital, Italy.

MATERIAL

Forty patients (male n = 25; female n = 15) with a mean age of 64.8 yrs. (range 35 to 82 yrs.) who underwent manual (n = 4; 10%) or stapled (n = 36; 90%) colorectal anastomosis. The mean interval between the Hartmann's procedure and the colostomy closure was 259 days.

MAIN OUTCOME MEASURES

Mortality, morbidity, anastomotic complications.

RESULTS

No death was recorded. The overall complication rate was 37.5 per cent (n = 15 patients), being wound infection the most common (n = 9). Complications of the colorectal anastomosis were observed in n = 5 patients (12.5%). In details, four patients (10%) developed stenosis of the anastomosis and one (2.5%) bled from the suture line. No instance of leak was observed. Surgery was required to correct a recurrent stenosis of the colorectal anastomosis.

CONCLUSION

Restoration of the bowel continuity after Hartmann's procedure is safe and has an acceptable rate of general and anastomosis-related morbidity. Most of the anastomotic complications will resolve without further surgery.

Is laparoscopic sonography a reliable and sensitive procedure for staging colorectal cancer? A comparative study

BACKGROUND

Laparoscopic colectomy has developed rapidly with the explosion of technology. In most cases, laparoscopic resection is performed for colorectal cancer. Intraoperative staging during laparoscopic procedure is limited. Laparoscopic ultrasonography (LUS) represents the only real alternative to manual palpation during laparoscopic surgery.

METHODS

We evaluated the diagnostic accuracy of LUS in comparison with preoperative staging and laparoscopy in 33 patients with colorectal cancer. Preoperative staging included abdominal US, CT, and endoscopic US (for rectal cancer). Laparoscopy and LUS were performed in all cases. Pre- and intraoperative staging were related to definitive histology. Staging was done according to the TNM classification.

RESULTS

LUS obtained good results in the evaluation of hepatic metastases, with a sensitivity of 100% versus 62.5% and 75% by preoperative diagnostic means and laparoscopy, respectively. Nodal metastases were diagnosed with a sensitivity of 94% versus 18% with preoperative staging and 6% with laparoscopy, but the method had a low specificity (53%). The therapeutic program was changed thanks to laparoscopy and LUS in 11 cases (33%). In four cases (12%), the planned therapeutic approach was changed after LUS alone.

CONCLUSIONS

The results obtained in this study demonstrate that LUS is an accurate and highly sensitive procedure in staging colorectal cancer, providing a useful and reliable diagnostic tool complementary to laparoscopy.

Association between perioperative blood transfusion and dehiscence of anastomosis after rectal resection for cancer

Perioperative blood transfusion (PBT) has proved to increase the risk of sepsis after surgery. The hypothesis that PBT also might increase the occurrence of leak of rectal anastomoses has been tested. The data of 94 patients undergone low anterior resection for rectal cancer were reviewed. Thirty-nine of them (41%) received one or more packed red cells (PRC) units perioperatively. The total dehiscence rate was 14% (13 cases), and it was significantly lower in not-transfused (4%) compared to transfused patients (28%) (p < 0.005). The risk of dehiscence was increased by six-fold if up to two, and by fifteen-fold if more than two PRC units were given. These findings suggest that leakage of rectal anastomoses should be considered among the detrimental effects of PBT. The risk of dehiscence increases with the number of units transfused. A judicious administration of blood might contribute to reduce this complication.