1,721,017 research outputs found
Colecistectomia laparoscopica nella colecistite acuta: timing e outcome
Full text linkLa colecistite acuta è una malattia comune con alta prevalenza e notevoli costi sociali. Colpisce circa il 10-25% della popolazione adulta e circa il 20% di questi svilupperà complicazioni che richiedono un intervento chirurgico. Negli ultimi 25 anni si è registrato un aumento della prevalenza della patologia. Tale aumento è ascrivibile all’aumento dei fattori predisponenti (soprattutto nei paesi occidentale) e ad un aumento della longevità (essendo la litiasi della colecisti e le sue complicanze una malattia dell’anziano). Sebbene sia una patologia benigna, è oggi una malattia che influisce significativamente sui costi sociali, sia diretti (i costi sanitari per l’ospedalizzazione e per le cure) sia indiretti (la convalescenza e le giornate lavorative perse con conseguente diminuzione della produttività). Le complicanze legate all’evoluzione della malattia comportano un aumento della degenza ma anche un aumento delle complicanze post-operatorie. In numerosi studi in letteratura possiamo trovare come l’intervento chirurgico in urgenza aumenti il tasso di complicanze post-operatorie. Tali numeri rimangono alti anche in questi anni di miglioramento della tecnologia a supporto del chirurgo. Con il nostro studio abbiamo pensato di raccogliere dati sulle colecistectomie eseguite per litiasi della colecisti (sia in elezione che in urgenza) di due centri universitari (il Policlinico Sant’Orsola di Bologna e l’Ospedale Umberto I di Roma – La Sapienza) e quelli di un centro ospedaliero dell’AUSL di Bologna (Ospedale di Bentivoglio). Il DB condiviso ha permesso di poter indagare in primo luogo i fattori responsabili della conversione e delle morbidità post-operatorie, l’incidenza dell’età sugli outcome operatori ed il timing di intervento. Tutti questi dati sono stati poi raccolti ed analizzati. Siamo giunti alla conclusione che non esistono fattori modificabili che possano in qualche modo “evitare” le complicanze post-operatorie. Esistono invece alcuni fattori modificabili, come il timing (già indicato dalle Tokyo Guideline 2018) e la gravità della patologia (la colecistite acuta gangrenosa). Pertanto dopo un primo periodo di analisi retrospettiva abbiamo utilizzato un algoritmo di Learning Machine per poter determinare quali colecisti debbano essere operate subito e quali possano beneficiare del “raffreddamento” Nei prossimi anni, implementando l’algoritmo e aumentando i casi clinici, potremmo definire se tale algoritmo possa aiutare i clinici nella giusta scelta
IDENTIFYING PATIENTS WITH RIGHT ILIAC FOSSA PAIN AT VERY LOW RISK OF APPENDICITIS: PROSPECTIVE, MULTICENTRE VALIDATION AND CALIBRATION OF RISK SCORES
No full textRIGHT SIDED DIVERTICULITIS IN EMERGENCY AND ELECTIVE SETTINGS: A SINGLE CENTRE EXPERIENCE
No full textIntroduzione
Right sided colonic diverticulitis is a rare condition in Western countries while is common in Asian ones. In most cases, right colonic diverticulitis mimicks an acute appendicitis and it is often diagnosed when explorative laparoscopy excludes the presence of appendicits. We report our experience in the treatment of right-side diverticulitis.
Pazienti e metodi
From September 2011 to May 2015 170 patients underwent surgical intervention for diverticular disease in our unit, both in emergency or elective setting. Pre- intra- and postoperative data of patients were prospectively registered. Uni and multivariate analysis was performed both for factors associated with postoperative morbidity and conversion to laparotomy. Statistical analysys was performed with SPSS v. 13.0. Significance was considered for p value < 0.05.
Risultati
17 patients (10%) was affected by right colonic diverticulitis and only 3 of them (17.6%) came from Asian countries. Male/female ratio was 1:1 with mean age of 5115 years, statistically lower respect to our cohort of patients with left side diverticulitis (6714 years; P<0.001). In 16 cases (94,1%) a surgical exploration was performed due to clinical and laboratoristic diagnosis of acute appendicitis. Only one patient underwent elective surgery for recurrent episodes of acute diverticulitis that required two hospital admissions. In 9 cases (52.9%) the disease was localized in the ascending colon while in the other 8 patients there was a caecal diverticulitis. 12 patients (70.6%) had Hinchey 1-2, in one case there were a generalized purulent peritonitis and in one case we found hemoperitoneum from diverticular bleeding. 13 patients (76.5%) underwent colonic resection with anastomosis while in the other 4 cases a diverticulectomy was performed with no postoperative events. Surgical interventions were performed with mini-invasive approach in 13 patients (76.5%) with a conversion rate of 29.4% (5 patients). Mean postoperative stay was 9 11 days. Overall postoperative morbidity rate was 12.6% (3 patients) according Calvien Dindo Classification. There was no postoperative in-hospital mortality. We also performed multivariate analysis to identify factors predicting overall, surgical ad medical complications but we did not find any significant factor. Also the logistic regression to identify factor predicting conversion from laparoscopic to open approach failed to find an independent variable.
Conclusioni
In our experience, right side colonic diverticulitis is a rare but not irrelevant condition also in Caucasian young individuals. Clinical and laboratoristic features of right diverticulitis can mimick other pathological contidion as acute appendicitis and often is misdiagnosed. Patients with acute right colonic diverticulitis can be treated safely with colonic resection and anastomosis. In selected cases isolated diverticulectomy can be an adequate approach
Small bowel obstruction due to metastasis of cutaneous melanoma: 7-years after primary diagnosis.
No full textAim of study: Metastatic involvement of the small bowel by melanoma is rare. The average time from the excision of the primary cutaneous melanoma to the occurrence of intestinal metastases tends to be between 3 and 5 years; one case of recurrence after 15 years is described.
The most common kind of lesion is polypoid: this can cause intussusception and intestinal occlusion. We report a case of intestinal occlusion by an ileal metastasis of a melanoma occurred 7 years earlier.
Materials and Methods: Case Report: The patient was a 57-year-old female who was admitted to our hospital for persistent abdominal pain and sub-occlusion. The patient's past medical history included cutaneous malignant melanoma 7 years before and lobular breast adenocarcinoma 10 years before. During the previous three months, she had intermittent abdominal pain and a weight loss of about 7 kg. Abdominal-US, EGDS and colonoscopy were all negative for pathologic findings. During the hospital stay, a CT enterography revealed lower intestinal intussusception, and enlarged lymph nodes both in the abdominal cavity and in the retroperitoneum. Intraoperatively we found an ileal invagination due to a polypoid mass of the ileal tract. Segmental ileal resection was performed; wide mesenteric lymph node dissection was not possible because of large and extended retroperitoneal lymphadenopathies. Histological examination showed epithelioid and spindle tumor cells with obvious cytoplasmic melanin deposition. Immunohistochemical staining revealed that tumor cells were positive for S-100, HMB-45 and vimentin, confirming the diagnosis of melanoma.
Main results and conclusions: Appearance of GI metastases is reported up to 15 years after the inital diagnosis of melanoma. Reported clinical signs and symptoms generally include chronic abdominal pain, occult or gross bleeding and, as in this case, weight loss. Aspecificity of symptoms may impede early diagnosis and treatment of the disease. As in this case, where curative surgery is impossible because of the extent of disease, metastatic tumor resection or GI tract bypass surgery is recommended to relieve symptoms or avoid future complications. Early diagnosis of metastases requires adequate imaging (CT) and prolonged follow up
Laparoscopic repair for perforated peptic ulcer: our experience, a comparison with the open approach and a review of the literature.
Full text linkBackgrounds:
The incidence of perforated peptic ulcers has decreased during the last decades but the optimal treatment for these patients remains controversial. At the same time, a laparoscopic approach to this condition has been adopted by an increased number of surgeons. Therefore, this study wants to evaluate the postoperative results of the laparoscopic treatment of perforated peptic ulcer performed in one Italian center with extensive experience in laparoscopic surgery.
Methods:
This retrospective study includes 94 patients who were operated for perforated peptic ulcer peritonitis at “St. Orsola Hospital - Emergency Surgery Unit - University of Bologna” from May 2014 to December 2019. The patients’ charts were reviewed for demographics, surgical procedure, complications, and short-term outcomes.
Results:
The diagnosis was made clinically and confirmed by the presence of gas under diaphragm on abdominal X-ray. All patients underwent primary suture repair with or without omentopexy. Boey score 0 or 1 was found in 66 (70%) patients, Boey 2 or 3 in 28 (30%) patients. The operative time was between 35 and 255 minutes, with a mean of 93 minutes. The overall median hospital stay was 9.5 (1-60) days. Post-operative complications occurred in 19 (20%) patients and 18 (19%) patients died.
Conclusions:Perforated peptic ulcer is a severe condition that requires early hospital admission and immediate surgery. Laparoscopy in experienced centers and for selected patients is safe, associated with optimal outcomes and should be the preferred approach
SHORT TERM RESULTS OF ELECTIVE COLON RESECTIONS FOR UNCOMPLICATED DIVERTICULAR DISEASE
No full textIntroduzione
Indications for elective surgery in diverticular disease are sill debated and recent findings suggest a conservative approach since most patients present complicated diverticulitis as the first manifestation of diverticular disease. In our study we analyze the result in term of postoperative morbidity and mortality in patiets who underwent elective surgery for diverticular disease.
Pazienti e metodi
From September 2011 to May 2015 we perfomerd 170 surgical interventions for diverticular disease in our unit. Of these, 51 resection were performed in elective setting. Pre-, intra- and postoperative findings were collected in a prospective database. Multivariate analysis with logistic regression was performed to find out independent predictive factors for postoperative events. Statistical analysis was made with SPSS v.13.0 and significance was considered with p value < 0.05.
Risultati
Male:Female ratio was 1:1 with mean age of 5914 years. 44 patients was younger than 75 years. 54.9% of patients had one or more comorbidities and 12 patients (23.5%) had ASA score >2. Most patients had only one previous hospital admission (28 patients, 54.9&) while 9 patients reported two or more admissions. 2 patient underwent surgery for the development of colo-vescical or colovaginal fistula and 2 patient for paracolic or pelvic abscess refractory to medical therapy. In 70.6% (36 patients) of cases a laparoscopic approach was performed with a conversion rate of 16.7%. No postoperative in-hospital mortality was recorded. Postoperative complication rate was 31.4% (16 patients) according Clavien-Dindo Classification. Anyway 14 patients had grade I or II complication with mild clinical impairment. Multivariate analysis did not find any independent predictive factor for overall and surgical complications. On the other hand presence of diabetes mellitus (DM) and ASA score > 2 was associated with increased risk of medical complication (OR 16.7; 95%CI 1.1-259.9 P=0.044 and OR 8.5; 95%CI 1.1-62.6 P=0.036 respectively). A T-test was performed to compare mean of postoperative stay within the two variables. Patients with ASA score > 2 were found to have longer postoperative stay respect to those with ASA score 1-2 (13,5 vs 8,4 P=0.008). No significant difference was found in patients with or without DM (9.0 vs 9.6 P=0.818).
Conclusioni
In our experience, elective surgery for diverticular disease can be performed safely and often with mini-invasive approach, with accetable rate of significant postoperative event. Anyway we need powerful studies providing strong evidence to identify patients who could really take advantage of elective surgical intervention
FACTORS PREDICTING MORBIDITY AND MORTALITY AFTER SURGERY FOR COMPLICATED ACUTE DIVERTICULITIS: A SINGLE CENTER EXPERIENCE
No full textIntroduzione
Complicated acute diverticulitis (CAD) occurs in approximately 10 to 25 percent of patients affected by diverticular disease and a surgical treatment is often necessary. Postoperative morbidity and mortality are still high, up to 40% of cases in patients with generalized peritonitis. The purpose of this study is to identify predictive prognostc factor for postoperative morbidity and mortality in patients requiring surgical intervention for CAD.
Pazienti e metodi
From September 2011 to May 2015 170 patients underwent surgical intervention for diverticular disease in our unit. Of these, 119 patients required urgent surgery for complicated acute diverticulitis (CAD). Pre-, intra- and postoperative findings were collected in a prospective database. Multivariate analysis with logistic regression was performed to find out independent predictive factors for postoperative morbidity and mortality. Statistical analysis was made with SPSS v.13.0 and significance was considered with p value < 0.05.
Risultati
There were 56 males and 63 females with mean age of 68 ± 15 years. 100 patients (84.0%) were at first hospital admission for diverticular disease and in 16 cases (13.4%) the disease was localized at right colon or ceacum. A stomy was required in 84 patients (70.6%) and postoperative morbidity rate was 52,9% according Clavien–Dindo Classification. Anyway only 10.9% of patients were affected by grade III or IV complication with a mortality rate of 16.8%. At multivariate analysis the presence of a postoperative medical complication was the only predictive factor for mortality (OR 10.3; 95%CI 2.1-51.3 p=0.004) while the presence of COPD and purulent or fecal peritonitis were not statistically significant (OR 3.3; 95%CI 0.9-12.2 p=0.073 and OR 3.1 95%CI 0.8-11.6 p=0.099 respectively). For postoperative morbidity the logistic regression showed that patients ≥75 years and with ASA score > 2 were independently associated with postoperative morbidity (OR 2.8; 95%CI 1.1-7.2 p=0.028 and OR 5.3 95%CI 2.0-13.9 p=0.001 respectively). The same factors were independent prognostic factor associated with medical complication with OR 3.0; 95%CI 1.1-7.8 p=0.028 and OR 6.5 95%CI 2.0-21.3 p=0.002 respectively. Multivariate analysis of factor predicting surgical morbidity showed that age ≥75 was the only predictive factor for postoperative surgical morbidity (OR 3.1; 95%CI 1.1-8.8 P=0.027).
Conclusioni
In our experience the majority of patients who require surgery for CAD are at the first episode of acute diverticulitis. Medical complication after surgery for CAD is the only factor associated with mortality while surgical complications do not seem to have the same weight. Age≥75 years and ASA score >2 are independent predictive factors for postoperative medical complications while only age seems to have a significant effect on surgical morbidity
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
FEATURE IN YOUNG PATIENTS SURGICALLY TREATED FOR ACUTE DIVERTICULITIS
No full textIntroduzione
There is lack of consensus whether to consider acute diverticulitis in younger patients a more aggressive disease than in other. While some authors considered diverticulitis in younger worst than in older patients, others suggested similar outcomes. In this study we evaluate differences between patients 45 years old and > 45 who underwent surgery for acute diverticulitis.
Pazienti e metodi
From September 2011 to May 2015 119 patients underwent emergency surgical intervention for acute diverticulitis in our unit. Pre-, intra- and postoperative findings were collected in a prospective database. 12 patients (Group A, 10,1%) were 45 years old. We compared clinical and pathological data between Group A patients and the remaining 145 (Group B 89.9) to find out any difference for characteristics of patients, clinical presentation, operative and short-term results. Uni- and multivaiate analysis were performed with SPSS v. 13.0 and satistical significance considered with p value < 0.05.
Risultati
Slight difference between Group A and Group B was found about presence of males (75.0% vs 43.9%; p=0.065). Significant differences were found for patients with one ore more comorbidities (16.7% vs 86.9%; p<0.001) and in particular for cardiovascular diseases (0% vs 67.3; p<0.001). Also ASA score was lower in younger patients with ASA 1-2 in 91.7% of patients versus 29.0% in group B patients (p<0.001). Localization of disease differed between two group with prevalence of right colonic side in 41.7% of Group A patients rspect to 10.3% of older patients (p=0.010). Group A patients treated in emergency were at first admission in 91.7% of cases respect to 83.2% of group B but this difference was not found to be statistically significant (p=0.688). In group A, laparoscopy was performed in 50% of patients while in group B only in 20.6% of cases (p=0.033) with no difference in conversion rate. The majority of Group A patients did not required an ostomy after surgical exploration respect to Group B patients (33.3% vs 74.8% p=0.006). No significant difference was found for the incidence of purulent or fecal generalized peritonitis (33.3% vs 57.9%; p=0.131). For postoperative results, morbidity rate according Clavien-Dindo classification was lower in Group A patients (8.3% vs 57.9%; p=0.001) and also the incidence of medical complications favoured younger patients (8.3% vs 44.9%; p=0.015). On the other hand the two groups did not differ for postoperative mortality (8.3% vs 17.8% p=0.688). Mean length of postoperative stay was shorter in Group A patients respect to Group B (6.32.0 vs 15.314.6; p=0.002). Multivariate analysis between Group A and B showed only a higher incidence of ostomy after surgery in group B (HR 4.0; 95%CI0.85-19.0) that did not reached statistical significance (p=0.08).
Conclusioni
Acute diverticulitis in young patients shows some peculiar issues, in particular for the localization of the disease, but does not seem to be more aggressive than in older people. For these reasons surgical intervention should be taken into account not considering age but the actual clinical, laboratoristic and instrumental findings
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