Search

Introduction Stenotrophomonas Malthophilia (SM) is generally considered a nosocomial pathogen but it has also been reported as a cause of community-acquired systemic infection. We reported a rare case of SM multi-organ infection involving the liver and the left ocular region. Presentation of the case A 64 years old man presented with fever for 4 days and acute blindness of the left eye. We performed an abdomen and head CT scan that identified respectively a liver lesion in central region, likely a hepatic abscess, and inflammation process involving the left eye. After 5 days of antibiotic therapy, no improvement of the clinical condition was noted. A CT guided drainage of the hepatic abscess was performed. SM was identified in the content of the drain and selected antibiotic therapy with combination of tygecycline and TMP-SMX was immediately initiated. After 15 days of the selected therapy, the hepatic abscess and the left eye infection were completely resolved but unfortunately the patient reported permanent blindness. Discussion Several studies identified most of the SM infections as nosocomial, however that can be excluded in this case because the patient presented signs of severe systemic infection 72 h before the hospitalization. The conservative treatment, with a combination of CT guided drainage and selected antibiotic therapy, gave good results. Conclusion Although SM is thought to be a nosocomial pathogen, it can be involved in severe systemic sepsis affecting different organs outside the hospital setting. Fortunately, the combination of tigecycline with TMP-SMX seems to be the best therapeutic option.

Background Pilonidal disease is a morbid condition of the young population, that could impair quality of life with a high cost for the health care system. No consensus exists on optimal surgical treatment, even if several techniques have been proposed. In this preliminary case-control study we compared excision by knife and diathermy to investigate if wound dehiscence could be related to heat spreading during excision of the sinus. Materials and method Between January 2017 and February 2018, 29 patients underwent to sinus excision.16 patients underwent sinus excision by diathermy (named “Hot” group, case-group) while 13 patients underwent excision by the knife as the control group (named “Cold” group). The temperature data were recorded for both groups. Were considered primary and secondary outcomes. Results the cold group has worse outcomes in operative time and blood loss, but better results in post-operative pain at first day and first control, number of weekly and total dressings until healing, time for full wound recovery, days to return to work, patient feeling feedback and scar aspect. Wounds healed within 8–12 days were 84.6% in the Cold group and 18.8% in the Hot one. I° Dindo-Clavien complications were respectively 15.4% and 100.0% for the Cold and Hot group. No differences were recorded for II° Dindo-Clavien complications and in days of hospitalization. Conclusion cold excision of the sinus pilonidalis has better results both in terms of precarious healing and quality of life, probably because the tissues are not subjected to diathermocoagulation damage and therefore the healing occurs more quickly. (United States National Institutes of Health, www.clinicaltrial.gov, number NCT 03764657, www.researchregistry.com UIN 5003)., Highlights • Pilonidal sinus disease. • Cold and Hot surgical procedures. • Wounds healed within 8–12 days were 84.6% in the Cold group and 18.8% in the Hot one. I° Dindo-Clavien complications were 15.4% for the Cold and 100.0% for the Hot group.

Objective Swallowing and voice impairment are common after thyroidectomy. We evaluated short-term functional changes in esophageal motility in a series of patients who had undergone total thyroidectomy. Several studies have investigated these symptoms by means of interviews or questionnaires. Study Design Prospective study. Setting Academic research. Materials and Methods Thirty-six consenting patients were prospectively recruited. Eligibility criteria were thyroid volume ≤60 mL, benign disease, and age between 18 and 65 years. Exclusion criteria were previous neck surgery, severe thyroiditis, hyperthyroidism, and pre- or postoperative vocal cord palsy. Voice impairment score, swallowing impairment score, lower esophageal sphincter pressure, esophageal motility, upper esophageal pressure, and coordination were evaluated preoperatively and 30 to 45 days after surgery. Results Postoperative swallowing impairment (appearance or worsening of dysphagia) was found in 20% of patients and voice impairment in more than 30%. Both preoperative and postoperative esophageal motility were similar. All patients showed an average decrease of 25% in upper esophageal pressure, although the pressure was within normal range. Swallowing alterations were associated with upper esophageal incoordination (P < .03), and proximal acid reflux was significantly associated with voice impairment (P < .02). Conclusion After uncomplicated thyroidectomy, decreased upper esophageal pressure may explain both pharyngeal (dysphagia) and laryngeal (vocal impairment) exposure to acid. In the future, proton pump inhibitor therapy protocols should be evaluated.

BACKGROUND: Patients undergoing thyroidectomy often complain aerodigestive disorders. In a previous study we showed the associations between voice impairment and proximal acid reflux, swallowing impairment and Upper Esophageal Sphyncter (UES) incoordination and the decrease in UES pressure in thirty-six patients observed before and soon afterwards uncomplicated thyroidectomy. This study investigated the state of post-thyroidectomy esophageal motility changes and its associations with these disorders after 18-24 months. PATIENTS AND METHODS: The thirty-six patients prospectively recruited according to selection criteria (thyroid volume ≤60 ml, benign disease, age 18-65 years, previous neck surgery, thyroiditis, pre- or postoperative vocal cord palsy) underwent voice (VIS) and swallowing (SIS) impairment scores, esophageal manometry and pH monitoring once again. RESULTS: After 18-24 months, both VIS and SIS recovered (respectively: p=0,022; p=0,0001); UES pressure increased (p=0,0001) nearing the preoperative values. The persistence of swallowing complaints were associated with the persistence of esophageal incoordination (p=0,03); the association between voice impairment and proximal acid reflux was confirmed (p

BACKGROUND: Fimctional constipation (FC) is a common disorder, particularly frequent m women. The aim of our study was to compare the results of balloon expulsion test with the manometry and defecography findings to exclude dyssynergic defecation (DD) in patients with chronic constipation. METHODS: From January 2005 to December 2011, 127 patients with the diagnosis of functional constipation were recruited retrospectively. They were divided into three groups: 24 with DD, 54 with descending perineum syndrome (PDS), 49 without DD/PDS. Diagnosis of DD was established by manometnc and defecographic fmdmgs according to Rome EH criteria. RESULTS: The balloon expulsion test was abnormal m 11 out of 24 patients with DD, 19 out of 54 with PDS and 13 of 49 without both. Hie specificity and negative predictive value of the test for excluding dyssynergic defecation were 73% and 77%, respectively. There was no statistically significant association between the balloon expulsion test and findings in defecografy (P=0.31). There was a relevant association between mean resting pressure (MRP) and balloon expulsion test (P=0.002) on anorectal manometry. CONCLUSIONS: The balloon expulsion test is a simple and useful screening procedure to identify constipated patients who do not have DD. However, the balloon expulsion test cannot be used alone as a golden standard for the diagnosis of "dyssynergic defecation" and should be integrated with other anorectal tests mamly with anorectal manometry and secondly defecography. (Cite this article as: Inviati A, Scerrino G, Sckifano D, Di Giovanni S, Lo Greco V, Bonventre S. Can the balloon expulsion test be used to exclude the diagnosis of "dyssynergic defecation'? Gazz Med Ital - Arch Sci Med 2016;175:59-67).

Objective: Percutaneous tibial nerve stimulation is a recent and minimally invasive treatment for faecal incontinence (FI). The aim of this study is to evaluate the mid-term results in patients with idiopathic faecal incontinence (IFI). Methods: Fifty one patients (42 female and 9 male) were prospectively recruited. Patients were treated twice a week for 6 weeks as per study protocol. We have assessed the degree of fecal incontinence using the Cleveland Clinic faecal incontinence (CCF-FI) score at baseline, at 6 weeks, at 6 months and at 1 year. Also the anorectal manometric data (mean resting pressure (MRP), squeeze pressure (SP) and, rectal sensation) at baseline, at 6 weeks and at 6 months have been evaluated. Results: The median CCF-FI score was significantly decreased from an initial baseline value from 12 to 7 at 6 weeks, 3 at 6 months and, 3 at 1 year (respectively: 1st interquartile 4.5, 1, 0 vs 10; 3rd interquartile 9, 5, 5 vs 14.5, p = 0.0001). Anorectal manometry showed an improvement of the internal (resting pressure, MRP) and the external sphincters (squeeze pressure, SP) at 6 months compared to the baseline and 6 weeks by PTNS, while, RP and SP at 6 months was greater than at baseline and 6 weeks (p = 0.004 and p = 0.002 respectively). Conclusions: This study demonstrates that stimulation of the posterior tibial nerve could be an excellent procedure for the treatment of IFI. The stimulation of the posterior tibial nerve can improve the fecal continence (CCF-FI score) in the short term and this improvement is maintained after 1 year of follow-up without treatment

Background/Aims: Nutcracker esophagus and non-specific motility disorders are the main causes of non-cardiac chest pain (NCCP), with gastroesophageal reflux in 60% of cases. Achalasia and diffuse esophageal spasm are the most frequent anomalies described in patients with dysphagia. The goal of this study was to evaluate the occurrence of esophageal body and lower esophageal sphincter motor abnormalities in patients with dysphagia, NCCP, or both. Materials and Methods: This study is a retrospective analysis of 716 patients with NCCP and/or dysphagia tested between January 1994 and December 2010. 1023 functional studies were performed, 707 of which were esophageal manometries, 225 esophageal pH-meters, and 44 bilimetries. We divided the patients into three groups: group 1 was composed of patients affected with dysphagia, group 2 with NCCP and group 3 with NCCP and dysphagia. Results: Manometric anomalies were detected in 84.4% of cases (p

The consumption of soft drinks is a crucial factor in determining persistent hypocalcemia. The aim of the study is to evaluate the biochemical mechanisms inducing hypocalcemia in a female patient with usual high consumption of cola drink and persistent hypocalcemia, who failed to respond to high doses of calcium and calcitriol supplementation. At baseline and after pentagastrin injection, gastric secretion (Gs) and duodenal secretion (Ds) samples were collected and calcium and total phosphorus (Ptot) concentrations were evaluated. At the same time, blood calcium, Ptot, sodium, potassium, chloride, magnesium concentrations, and vitamin D were sampled. After intake of cola (1 L) over 180 min, Gs and Ds and blood were collected and characterized in order to analyze the amount of calcium and Ptot or sodium, potassium, magnesium, and chloride ions, respectively. A strong pH decrease was observed after cola intake with an increase in phosphorus concentration. Consequently, a decrease in calcium concentration in Gs and Ds was observed. A decrease in calcium concentration was also observed in blood. In conclusion, we confirm that in patients with postsurgical hypoparathyroidism, the intake of large amounts of cola containing high amounts of phosphoric acid reduces calcium absorption efficiency despite the high doses of calcium therapy.

AIM: Postoperative ileus has been considered an inevitable consequence of abdominal surgery. The aim of the study was to investigate the efficacy of same treatments in resolving postoperative ileus in various surgical approaches. METHODS: A total of 360 patients underwent abdominal surgery, and was divided into four groups: videolaparoscopic cholecystectomy, laparotomic colo-rectal surgery, laparotomic Hartmann procedure, laparotomic gastric surgery. In each group, patients received different postoperative treatments: chewing gum, olive oil, both, and water. Each group was compared with a control group. RESULTS: In patients who underwent videolaparoscopic cholecystectomy, median postoperative first passage of flatus and stool in the water group was 10 and 34 hours, respectively (P=0.006, P=0.021) and significantly earlier than in the control group (median postoperative 24 and 72 hours). Postoperative stay for the water group was lower (median day 1, 3rd interquartile 2.5) compared with control (median day 3; 3rd interquartile 7.0, P=0.01). In patients who underwent gastric surgery, median postoperative first passage of stool in the olive oil and chewing gum group was 48 hours, significantly earlier than in the control (median postoperative hour 120, P=0.04). Median time to first passage of flatus and stool was also earlier in the other groups compared with the control group, though this difference was not significant. CONCLUSION: Chewing gum, olive oil or both do not induce a relevant reduction of ileus after surgery. Water may be a safe and inexpensive option in reducing ileus. (United States National Institutes of Health, www.clinicaltrial.gov, number NCT01869231).

Prophylactic, compartment-oriented central neck dissection (CND) for cN0 papillary thyroid carcinoma (PTC) is not widely practiced. We examined our results with this surgical approach.A cohort of 158 patients operated on for the classical variant of PTC at a follow-up of 1-22 years (mean: 6.6) were enrolled. The patients with a preoperative diagnosis of cN0 PTC (group A, 59 patients) underwent total thyroidectomy (TT) + CND. In the patients with incidental postoperative diagnosis of malignancy (group B, 99 patients) a TT alone was performed.Ninety-six T1, 36 T2, 26 T3/T4 PTC patients were enrolled. The overall biochemical/scintigraphic recurrence rate (15 patients, 9.49%), was significantly higher in group B. Disease-free survival and need for postoperative radioiodine ablative treatment were more favorable in group A (P0.05; P0.001, respectively). The median radioiodine ablative treatment in the T2 cluster alone was lower in group A (P0.001). The morbidity rate was similar in both groups.Considering the acceptable morbidity, prophylactic CND seems to be advantageous in terms of recurrence rate and need for radioiodine treatment in this variant of PTC, at least in T2 or more advanced stages. The indolent behavior of PTC does not allow for reliable prognostic evaluations.

Minimally invasive video-assisted thyroidectomy (MIVAT) is a surgical technique that has showed increasingly good results, particularly in endocrine surgery centers. The aim of this prospective, non-randomized study was to evaluate feasibility, advantages and critical aspects of MIVAT in a general surgery unit.Two hundred twenty-four patients underwent total thyroidectomy for benign thyroid disease from May, 2008 to April, 2011. They were divided into two groups: one underwent conventional thyroidectomy (CT), and the other underwent MIVAT. The inclusion criteria were thyroid volume ≤35 mL and main nodule size ≤35 mm. For each patient, socio-demographic variables, hospitalization data and outcome measures (complication rate, operating time, post-operative pain, observer and patient scar assessment scale [OSAS and PSAS, respectively]) were collected. Multivariate regression analyses were done to assess the principal covariates affecting these outcome measures.There were 125 MIVATs and 99 CTs performed. The two groups were characterized by difference in age (38.4 vs. 50.9 years) and thyroid volume (18.6 vs. 23.3 mL). OSAS/PSAS scores were statistically significant in the MIVAT group (P0.001 and P0.001, respectively) even after adjusting for age and thyroid volume. Complication rate was similar in the two groups.MIVAT significantly decreased postoperative pain and improved cosmetic results. It can be performed in younger patients and in all cases in which there is a clear indication for the procedure. Its advantages were confirmed in a general surgery unit where correct indications were followed.

disphagia, non-cardiac chest pain

The aim of this retrospective study was to evaluate the impact of some risk factors on mortality in patients with Acute mesenteric ischemia (AMI).From September 2003 to August 2011, 200 patients were operated on for bowel infarction at our unit: 149 were included in the study. For each patient, socio-demographic (gender and age) and clinical data (extent of necrosis, predisposing factors, WBC, LDH, comorbidities) were collected from patients' clinical records.Of the 149 patients who underwent surgery, 57 (38.3%) died. A significantly higher mortality was associated with older age (79.9 versus 74.2 years, p0.01), higher LDH serum levels (695 versus 636 UI/L, p0.01), higher WBC (25.1 versus 22.5 X 103/mm3; p0.01), and extent of necrosis (p0.01). Otherwise, there was no correlation between comorbidities and mortality. Finally, multivariate analysis confirmed the significantly higher risk of death in patients with right colon and massive small bowel infarction (adjOR= 3.58; 95% CI=1.36-9.42) and intestinal perforation (adjOR=31.1; 95% CI=2.45-395.7).The results of our study suggest that the contribution of laboratory tests is limited, even if increased indexes of necrosis (such as LDH) associated with neutrophilic leukocytosis and metabolic acidosis, may help in defining diagnosis/ prognosis, though with low accuracy.The extent of necrosis and diagnostic delay seem to be the most important prognostic factors even after adjusting for confounding due to age, presence of comorbidities, and laboratory tests (LDH and WBC).Acute mesenteric ischemia, Mortality, Predictive factors.

Aim. Papillary thyroid carcinoma (PTC) is the most frequent thyroid malignancy with an overall ten-year survival more than 90%. Total thyroidectomy (TT) is considered the gold standard for PTC, but not all the endocrine surgeons agree on central neck dissection except in case of known metastases. Methods. We enrolled 158 patients, that underwent, between January 1990 and September 2012 total thyroidectomy±prophylactic CND for PTC. 59 Patients (group A) had a preoperative diagnosis of PTC; 99 (group B) had a diagnosis of benign disease. We focused on possible complications. Results. In group A we had 4 patients who blamed a definitive RLN palsy, only 1 patient in group B, with an OR=7.12. Definitive hypoparathyroidism was found respectively in 3 patients of group A and in 5 patients in group B, even in this case not statistically significant with an OR=1.007. Conclusion. We can affirm that the complications of thyroid surgery seem not to be strongly associated to the extent of surgery.

Introduction Hiatal hernia, defined as “transitory or stable dislocation of a part of the stomach in mediastinum through the diaphragmatic crura delimiting esophageal hiatus”. Its appearance presupposes anatomic anomalies or weakening of structures and mechanisms able to maintain esophago-gastric junction and stomach in the abdominal cavity [1]. Classically hiatal hernia was classified in four types using Hill’s classification: Type 1 hiatal hernia is associated with GERD in 50-90% of cases, in facts its presence gradually compromises esophago-gastric junction’s continence favouriting the backwater of acid secretion and its reflux in contact with esophageal mucosa during transient relaxations of the LES and also reducing clearing systems overall for large hiatal hernias [2, 3]. Several randomized controlled trials with long-term follow-up comparing surgical with medical therapy for the treatment of GERD, strongly support surgery as an effective alternative to medical therapy [4]. Fundoplication has also been demonstrated to lead to improved or at least comparable quality of life to that of medically treated patients and it is associated with high patients satisfactions rate [5]. A laparoscopic total fundoplication is considered today the procedure of choice increasing the resting pressure and length of the lower esophageal sphincter, decreasing the number of transient LES relaxations and improving quality of esophageal peristalsis and follow-up demonstrates complete symptoms control in 80-90% of patients 10 years later [6]. However primary laparoscopic hiatal hernia repair is associated with up 42% recurrence rate [7]. Several level data suggest that mesh reinforcement of the crural closure for hiatal hernia repair decreases the recurrence of hernia, but can lead to esophageal erosion and stenosis or disphagya, above all non-absorbable mesh [8, 9]. For this clinical case, we experiment a new totally absorbable Gore Bio-A® mesh [10]. Materials and methods: Clinical Case Female patient; 65-year old; 6-year classic history of GERD (regurgitation, belching, bloating, “acid in the throat” treated for several years by multiple proton pump inhibitors); BMI 22. An EGDS revealed a > 3 cm hiatal hernia, grade B Los Angeles esophagitis. 24-hour pH study was positive for acid reflux and esophageal manometry revealed LES intrathoracic dislocation. With laparoscopic 5-trocars approach, the hiatal hernia defect was identified and primarily repaired, by crural closure, with size 0 permanent suture (ETHIBOND). GORE BIO-A® Tissue Reinforcement was trimmed to fit the defect with a “U” shape cutout to accommodate the esophagus. It was secured using two absorbable sutures (VICYRL). At least A Nissen fundoplication was performed without incident. Result: Gore BIO-A® mesh was easily placed through a 10-12 mm trocar. It had good handling characteristics laparoscopically, and no pre-operative preparation was required of the prosthetic. It can be cut and tailored intraoperatively to an optimal adaptation. There were no short-term complications from the mesh. The patient had not significant post-operative sequelae. Conclusion Crural closure reinforcement during hiatal hernia repair can be done readily with this new totally absorbable Gore Bio A Tissue Reinforcement: it is a 3D web of completely absorbable synthetic polymers replaced by soft tissue over six months; it is a mix of glycolic acid and trimethylene carbonate and its function consistes in stimulating collagens deposition and ingrowth of new connective soft tissue [11]. It was demonstrated that Gore Bio-A increases cellular in-growth in 7-30 days more and more previously than biologics mesh; it also increases new blood vessels formation in 7-14 days reaching the greatest vascular in-growth. Instead the biologic meshes gore BIO-A seems to induce the least inflammatory infiltrate. Gore BIO-A tissue reinforcement seems to have all the best characteristics to hernia hiatal laparoscopic repair reducing both recurrence rates and post-operative mesh-related complications, even if several other cases and studies are necessary. However further data and studies are needed to evaluate long-term efficacy and complications associated with its use.

BACKGROUND: Prophylactic, compartment-oriented central neck dissection (CND) for cN0 papillary thyroid carcinoma (PTC) is not widely practiced. We examined our results with this surgical approach. METHODS: A cohort of 158 patients operated on for the classical variant of PTC at a follow-up of 1-22 years (mean: 6.6) were enrolled. The patients with a preoperative diagnosis of cN0 PTC (group A, 59 patients) underwent total thyroidectomy (TT) + CND. In the patients with incidental postoperative diagnosis of malignancy (group B, 99 patients) a TT alone was performed. RESULTS: Ninety-six T1, 36 T2, 26 T3/T4 PTC patients were enrolled. The overall biochemical/scintigraphic recurrence rate (15 patients, 9.49%), was significantly higher in group B. Disease-free survival and need for postoperative radioiodine ablative treatment were more favorable in group A (P