Publications by authors named "Mario Schietroma"

68 Publications

Haemobilia secondary to a cystic artery pseudoaneurysm as complication of VLC.

Acta Biomed 2021 04 30;92(S1):e2021125. Epub 2021 Apr 30.

Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila.

Introduction: The laparoscopic approach has become the gold standard for cholecystectomy. However, it could have some major complications. Among them, it can be considered postoperative pseudoaneurysms of the cystic or hepatic arteries. Haemobilia secondary to a cystic artery pseudoaneurysm is extremely rare.

Case Report: Here we present a case from our centre of haemobilia in association with a cystic artery pseudoaneurysm, as a late complication of VLC. An 18-year-old girl underwent laparoscopic cholecystectomy; during surgery, due to viscero-perietal tight adhesions and due to the close proximity of the cystic duct to the biliary ducts, we suspected a bile duct injury. So, decision was taken to convert to open surgery: a suture was performed to repair the coledocic duct injury and an endoscopic papillotomy was performed with subsequent positioning of an endoscopic plastic biliary endoprothesis at the hepatocholedochus. One month after surgery, the patient showed clinical signs of hypovolemic shock. She underwent Computed Tomography Angiography, showing a possible arterial lesion, just adjacent to surgical clip. Therefore, patient underwent angiographic examination, which confirmed an 8 mm pseudoaneurysm arising from cystic artery, just adjacent to surgical clips. Superselective catheterization of vessel was performed, and two coils were released, until obtaining complete exclusion of the vascular lesion. The patient was discharged five days after procedure, with good general condition.

Conclusion: Pseudoaneurysms of the cystic artery are uncommon entities, rarely reported in the literature, and often caused by cholecystitis or iatrogenic biliary injury. All conditions that are responsible for vessels' injuries could also cause haemobilia. Even if pseudoaneurysm of cystic artery with haemobilia is a rare event, it has to be considered as a complication of VLC. Angiographic approach should be the treatment of choice.
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http://dx.doi.org/10.23750/abm.v92iS1.10821DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8142751PMC
April 2021

Endoscopic Double-Pigtail Catheter (EDPC) Internal Drainage as First-Line Treatment of Gastric Leak: A Case Series during Laparoscopic Sleeve Gastrectomy Learning Curve for Morbid Obesity.

Minim Invasive Surg 2020 23;2020:8250904. Epub 2020 Dec 23.

Surgical Endoscopy Unit, ASL1 Abruzzo, San Salvatore Hospital, L'Aquila, Italy.

Objectives: The prevalence of morbid obesity has dramatically increased over the last several decades worldwide, currently reaching epidemic proportions. Gastric leak (GL) remains the potentially fatal main complication after sleeve gastrectomy (SG) for morbid obesity. To our knowledge, there are no standardized guidelines for GL treatment after laparoscopic sleeve gastrectomy (LSG) yet. The aim of this study was to represent our institutional preliminary experience using the endoscopic double-pigtail catheter (EDPC) as the method of internal drainage and propose it as first-line treatment in case of GL after LSG.

Methods: One hundred and seventeen patients were admitted to our surgical department and underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity from March 2014 to June 2019. In 5 patients (4.3%) of our series, GL occurred as a complication of LSG. EPDC was the stand-alone procedure of internal drainage and GL first-line treatment. The internal pig tail was endoscopically removed from 30 to 40 POD in all cases.

Results: Present data (clinical, biochemical, and instrumental tests) showed a complete resolution of GL, with promotion of a pseudodiverticula and complete re-epithelialization of leak. Follow-up was more strict than usual (clinical visit and biochemical test on 7, 14, and 21 day after discharge; a CT scan with gastrografin on 30 day from discharge if clinical visit and exams were normal).

Conclusion: This was a preliminary retrospective observational study, conducted on 5 patients affected by GL as a complication of LSG for morbid obesity. EDPC maintains the safety, efficacy, and nonexpensive characteristic and may be proposed as better first-line treatment in case of GL after bariatric surgery.
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http://dx.doi.org/10.1155/2020/8250904DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775182PMC
December 2020

Branch Duct - IPMN and PanIN, in IgG4-Autoimmune pancreatitis: A case report.

Clin Case Rep 2020 Nov 10;8(11):2111-2115. Epub 2020 Sep 10.

Department of General Surgery Department of Biotechnological and Applied Clinical Sciences University of L'Aquila L'Aquila Italy.

The presence of pancreatic lesions in patients with autoimmune pancreatitis requires histological diagnosis (percutaneous or endoscopic biopsy) to exclude malignancy. A nonspecific histology after endoscopic or percutaneous biopsy of a pancreatic lesion may require surgical excision and definite histology.
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http://dx.doi.org/10.1002/ccr3.2641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669378PMC
November 2020

Partial agenesis of dorsal pancreas. Report of two cases.

Int J Surg Case Rep 2020 10;77S:S17-S20. Epub 2020 Oct 10.

Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Department of Surgery, San Salvatore Hospital, Italy.

Introduction: Agenesis of the dorsal pancreas (ADP) is a rare congenital anomaly resulting in missing corpus and cauda of the pancreas. The possibility of finding this disorder is increasing with the use of advanced radiological techniques like CT scan or MRI.

Presentation Of Case: We reported 2 cases of a partial ADP as radiological finding: the first one was a 79-year-old asymptomatic patient who presented to perform a CT staging scan for bladder tumor, while the second case was a 73-year-old patient with obstructive jaundice and with suspected common bile duct calculi. In the second patient US, CT scan and MRI were performed, and after that also an ERCP was scheduled.

Discussion: The prevalence of agenesis of the dorsal pancreas is not exactly known; in the literature, only 50 cases have been reported. Its cause and pathogenesis are not fully understood. Some patients experience no symptoms, while others may develop hyperglycemia, diabetes mellitus, bile duct obstruction, abdominal pain, pancreatitis, or other conditions.

Conclusion: Considering that dorsal agenesis is sporadically found, often do not have related symptoms and it does not require a specific treatment, whether further examinations are needed to determine the type of agenesis remains questioned.
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http://dx.doi.org/10.1016/j.ijscr.2020.10.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7876736PMC
October 2020

A case of segmental hepatic necrosis complicating oxaliplatin and capecitabine chemotherapy A case report and review of the literature.

Ann Ital Chir 2020 Sep 28;9. Epub 2020 Sep 28.

Chemotherapy is associated with different patterns of histopathological changes of the non-tumor-bearing liver. Hepatic infarction represents a relatively rare condition; the prevalence in several series of consecutive autopsies is 1.1%. To the best of our knowledge, no cases of liver infarction secondary to chemotherapy have been reported to date. We report a case of segmental hepatic infarction following the adjuvant chemotherapy with Oxaliplatin and Capecitabine in a patient who had undergone total gastrectomy and distal esophagectomy for gastric cancer. Liver infarction is usually managed by conservative therapy; interventional procedures such as percutaneous imaging-guided drainage or surgical evacuation should be reserved in cases where septic complications occur, with development of a hepatic abscess from the necrotic area. It is important to avoid misdiagnoses with liver metastases in order to define the most appropriate clinical management strategy. KEY WORDS: Adjuvant chemotherapy, Gastric cancer, Liver infarction, Hepatic necrosis.
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September 2020

A rare case of cardiac tamponade masquerading as acute abdomen.

Int J Surg Case Rep 2020 3;77S:S121-S124. Epub 2020 Sep 3.

Department of General Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, Italy.

Introduction: Acute abdomen is any acute abdominal condition requiring a quick response. The incidence varies according to age and disease aetiology. The abdominal discomfort associated with extra-abdominal pathophysiology and thoracic conditions could mimic acute abdomen. In this case we report a rare case of a young patient with cardiac tamponade masquerading as acute abdomen.

Presentation Of Case: A 25-years-old African man presented to the Emergency Department with abdominal pain. An EKG was performed, which revealed sinus tachycardia, with electrical alternans and borderline reduced voltage. At the time of the admission to our unit, he had a clinical worsening and a CT scan of abdomen was performed, which demonstrated hepatomegaly, abundant pericardial effusion and thin right pleural effusion at the lung bases. An echocardiogram confirmed a circumferential pericardial effusion with initial collapse of the right ventricular free wall. It was decided to immediately transport the patient to the Cardiosurgery Unit of another hospital to undergo pericardiocentesis.

Discussion: Our experience with this case underlines the important point that patients with a large pericardial effusion may present with the clinical features of acute abdomen and peritonitis. Abdominal pain was the primary symptom that prompted this patient to seek medical attention.

Conclusion: Acute abdomen is any acute abdominal condition requiring a rapid, often surgical, treatment. Cardiac tamponade is a medical emergency. The differential diagnosis could be kept in mind by any emergency physician, surgeon and anaesthesiologist, because an incorrect diagnosis and therefore an incorrect treatment or a delay in pericardial evacuation can be life-threatening.
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http://dx.doi.org/10.1016/j.ijscr.2020.08.062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7876917PMC
September 2020

Laparoscopic sleeve gastrectomy: A role of inflammatory markers in the early detection of gastric leak.

J Minim Access Surg 2021 Jul-Sep;17(3):342-350

Department of Surgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.

Setting: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a bariatric option. Gastric leak (GL) is the most dreaded septic complication of LSG. Early detection and treatment of this complication may improve outcomes.

Objectives: This study investigates biomarkers that might be useful to predict GL before its clinical presentation in patients who underwent LSG.

Patients And Methods: This study, prospective observational, was carried out in 151 patients, who underwent LSG for morbid obesity between February 2014 and October 2019. Blood samples were collected before the operation and on post-operative days one, three and five to dose serum C-reactive protein (CRP), pro-calcitonin (PCT), fibrinogen, white blood cells (WBCs) count and neutrophil-to-lymphocyte ratio (NLR).

Results: GL occurred in 6 patients (3.97%). According to the receiver operating characteristics curve, NLR detected leak with remarkably higher sensitivity (100%) and specificity (100%) than CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5. Moreover, the area under the curve (AUC) of NLR (AUC = 1) was higher than the AUC of CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5, suggesting important statistical significance.

Conclusions: Because NLR and PCT detected GL with remarkably higher sensitivity and specificity than CRP, fibrinogen and WBC, these two markers seem to be more accurate for the early detection of this complication.
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http://dx.doi.org/10.4103/jmas.JMAS_3_20DOI Listing
September 2020

TNM: a simple classification system for complicated intra-abdominal sepsis after acute appendicitis.

Minerva Chir 2020 Dec 6;75(6):442-448. Epub 2020 Aug 6.

Department of Surgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.

Background: Delayed diagnosis in case of acute appendicitis (AA) could lead to complicated intra-abdominal sepsis (IAS). Grading systems are not commonly employed in the clinical practice, because they are too complicated or too specific. Therefore, we suggest grading the severity of complicated IAS after AA with a simple system: TNM, an acronym borrowed by cancer staging where T indicates temperature, N neutrophils, and M multiple organ failure (MOF). This prospective observational study evaluates the predictive value of the TNM score on mortality of patients with complicated IAS after AA.

Methods: Sixty-eight patients with complicated IAS after AA were treated. Three classes of attributes were chosen: temperature (T), neutrophils count (N), and MOF (M). After defining the categories T (T0-T4), N (N0-N3) and M (M0-M2), these were grouped in stages (0-IV). Variables analyzed for their possible relation to death were age, sex, temperature, neutrophils count, preoperative organ failure, immunocompromised status, stage (0-IV). Odds ratios were calculated in a univariate and multivariate analysis.

Results: TNM staging was: one patient stage 0; 16 patients at stage I; 26 patients at stage II; 16 patients at stage III; nine patients at stage IV. Death occurred in 15 patients (22%). Neutrophil count, preoperative organ failure, immunocompromised status, stages III-IV were potential predictors of postoperative death in univariate analysis; only stage IV was significant independent predictor of postoperative mortality in multivariate analysis.

Conclusions: TNM classification is very easy to use; it helps to define the mortality risk and is useful to objectively compare patients with sepsis.
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http://dx.doi.org/10.23736/S0026-4733.20.08274-7DOI Listing
December 2020

Squamous cell anal cancer: Management and therapeutic options.

Ann Med Surg (Lond) 2020 Jul 12;55:36-46. Epub 2020 May 12.

Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila, Italy.

The incidence of anal cancer has increased during the second half of the 20th century, with an incidence rate over 2.9% greater than in the decade of 1992-2001. Yet, it still constitutes a small percentage, about 4%, of all anorectal tumours. Its risk factors are human papillomavirus infection, a history of sexually transmitted diseases, a history of vulvar or cervical carcinoma, immunosuppression related to human immunodeficiency virus infection or after organ transplantation, haematological or immunological disorders, and smoking. The most frequent symptom is rectal bleeding (45%), followed by anal pain, and sensation of a rectal mass. The diagnosis requires clinical examination, palpation of the inguinal lymph nodes, high resolution anoscopy followed by fine-needle aspiration biopsy or core biopsy. Subsequent histologic diagnosis is necessary, as well as computed tomography or magnetic resonance imaging evaluation of the pelvic lymph nodes. Since 1980, patients with a diagnosis of anal cancer have shown a significant improvement in survival. In Europe during the years 1983-1994, 1-year survival increased from 78% to 81%, and the improvement over 5 years was between 48% and 54%. Prior to 1974, patients with invasive cancer were routinely scheduled for abdominoperineal amputation, after which it was demonstrated that treatment with 5-fluorouracil and radiotherapy associated with mitomycin or capecitabine could be adequate to treat the tumour without surgery. Today, numerous studies have confirmed that combined multimodal treatment is effective and sufficient.
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http://dx.doi.org/10.1016/j.amsu.2020.04.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240186PMC
July 2020

Gastrointestinal bleeding as a result of entero-iliac fistula due to intestinal foreign body.

Ann Med Surg (Lond) 2020 May 1;53:20-22. Epub 2020 Apr 1.

Department of Surgery, San Salvatore Hospital. Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy.

Ingested toothpicks are a relatively rare event, but they may cause serious gut injuries and can be listed among rare causes of perforation, peritonitis, sepsis or death. Unless the foreign bodies were intentionally swallowed, many patients who ingested them fail to remember the event and they do not refer it during the medical history collection; this makes diagnosis problematic. In this work, a case of perforation of the sigmoid colon is described, caused by a toothpick ingestion. The patient had to be surgically treated because of a complication: the formation of an entero-iliac fistula with subsequent development of a pseudoaneurysm of the right external iliac artery. Vascular perforation due to toothpick ingestion has rarely been reported. In similar cases, it could be difficult to establishing the correct diagnosis because of the low sensitivity and accuracy rates of diagnostic investigations. The ingestion of foreign bodies should be kept in mind as an important differential diagnosis in patients with acute abdomen or chronic abdominal pain of unknown origin.
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http://dx.doi.org/10.1016/j.amsu.2020.03.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7149406PMC
May 2020

A case of three rare uterine neoplasms in the same surgical specimen.

Ann Ital Chir 2020 Jan 19;9. Epub 2020 Jan 19.

Background: Uterine sarcomas are mesenchymal tumors; they are rare, representing less than 2-3% of all uterine malignancies. Among them, we can define four types: leiomyosarcoma (LMS), endometrial stromal sarcoma (ESS), Adenosarcoma and Carcinosarcoma. This last type was recently reclassified by FIGO as a Mullerian type of the endometrial adenocarcinoma. Therefore, today only the first three types are histologically considered.

Methods: In this paper, we reported a case of simultaneous presence of three different rare neoplasms in the same surgical specimen, resulting from a hysterectomy of a premenopausal woman. The woman presented to the ED with a six-months history of vaginal bleeding. Given the complexity of the clinical picture, we suggested hospitalization in our Department of Gynecology, to perform appropriate diagnostic tests. Because of the persistent hemorrhage and the absence of required fertility preservation, a laparotomic hysterectomy with bilateral annessiectomy was performed.

Results: The postoperative histology of the specimen described the myoma at the fundus as a leiomyosarcoma. The myoma of the uterine anterior wall appeared as an endometrial stromal sarcoma of low-grade. Moreover, an intramural cavernous hemangioma of 3 cm in diameter was reported at the uterine corpus.

Conclusion: All these described pathologies have no specific clinic characteristics; the most common symptom is abnormal uterine bleeding. To date, hysterectomy and bilateral salpingo-oophorectomy are the standards of care in the management of all early stage uterine sarcomas. To our knowledge, cases of LMS, ESS and cavernous haemangioma coexisting in the same patient have not been reported in literature to date. The pathogenesis of this combination remains to be elucidated. Key words: Cavernous hemangioma, Endometrial stromal sarcoma, Leiomyosarcoma, Uterine sarcomas.
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January 2020

Relationship between haemorrhoidal grade and toilet habits.

Ann Ital Chir 2020 ;91:192-195

Purpose: Haemorrhoids are defined as the distal displacement and venous distention of the normal hemorrhoidal cushions. Multiple factors have been claimed to be causes of hemorrhoidal development, but the exact pathophysiology is poorly understood. The objective of this study was to assess how common is the habit to spend a long time on the toilet in patients seen for hemorrhoidal disease. Our hypothesis is that haemorrhoids could be significantly associated with a long sitting time because this practice contributes to the weakening and then dilatation of the hemorrhoidal cushions.

Methods: The survey was conducted from April 2019 to June 2019. The study group consisted of 52 adult non-obese patients with diagnosed internal or external haemorrhoids. These patients have been asked to fill an anonymous short questionnaire. We divided the group into four classes and we calculated the mean time spent on the toilet for each group. Then we realized a plot to assess a relationship among these two variables.

Results: We found that the two studied variables (time spent on the toilet and degree of haemorrhoids) seemed to be linked by a linear association (R2=0.95).

Conclusion: The results obtained in our preliminary study encourage us to continue this work, increasing the number of patients. If our supposition should be confirmed by further studies, we could say that toilet habits modification should be advised to any patients with any degree of haemorrhoids, as a part of treatment and as a preventive measure.

Key Words: Haemorrhoids, Goligher's classification, Constipation, Toilet habit.
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January 2020

Poorly differentiated neuroendocrine rectal carcinoma with uncommon immune-histochemical features and clinical presentation with a subcutaneous metastasis, treated with first line intensive triplet chemotherapy plus bevacizumab FIr-B/FOx regimen: an experience of multidisciplinary management in clinical practice.

BMC Cancer 2019 Oct 16;19(1):960. Epub 2019 Oct 16.

Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.

Background: Neuroendocrine tumors (NETs) are heterogeneous, widely distributed tumors arising from neuroendocrine cells. Gastrointestinal (GI)-NETs are the most common and NETs of the rectum represent 15, 2% of gastrointestinal malignancies. Poorly differentiated neuroendocrine carcinomas of the GI tract are uncommon. We report a rare case of poorly differentiated locally advanced rectal neuroendocrine carcinoma with nodal and a subcutaneous metastasis, with a cytoplasmic staining positive for Synaptophysin and Thyroid Transcription Factor-1.

Case Presentation: A 72-year-old male presented to hospital, due to lumbar, abdominal, perineal pain, and severe constipation. A whole-body computed tomography scan showed a mass of the right lateral wall of the rectum, determining significant reduction of lumen caliber. It also showed a subcutaneous metastasis of the posterior abdominal wall. Patient underwent a multidisciplinary evaluation, diagnostic and therapeutic plan was shared and defined. The pathological examination of rectal biopsy and subcutaneous nodule revealed features consistent with small-cell poorly differentiated neuroendocrine carcinoma. First line medical treatment with triplet chemotherapy and bevacizumab, according to FIr-B/FOx intensive regimen, administered for the first time in this young elderly patient affected by metastatic rectal NEC was highly active and tolerable, as previously reported in metastatic colo-rectal carcinoma (MCRC). A consistent rapid improvement in clinical conditions were observed during treatment. After 6 cycles of treatment, CT scan and endoscopic evaluation showed clinical complete response of rectal mass and lymph nodes; patient underwent curative surgery confirming the pathologic complete response at PFS 9 months.

Discussion And Conclusions: This case report of a locally advanced rectal NEC with an unusual subcutaneous metastasis deserves further investigation of triplet chemotherapy-based intensive regimens in metastatic GEP NEC.
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http://dx.doi.org/10.1186/s12885-019-6214-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6796336PMC
October 2019

Giant Spigelian Hernia presenting as small bowel obstruction: Case report and review of literature.

Int J Surg Case Rep 2019 24;63:118-121. Epub 2019 Sep 24.

Department of General Surgery, Hospital San Salvatore L'Aquila, University of L'Aquila, Italy.

Introduction: Spigelian Hernia is an uncommon pathology of abdominal wall (0.12-2.4%), usually small sized and with vague symptoms. It rarely presents as Small Bowel Obstruction or reaches dimensions that becomes clinically remarkable.

Presentation Of Case: 84-year-old woman entered our Surgical Department for Small Bowel Obstruction due to a giant (8 × 7 cm) abdominal wall hernia, which was intraoperatively identified as Spigelian Hernia. We performed a minilaparotomy with reduction of viable small bowel and preperitoneal positioning of polypropilene mesh. Postoperative course was uneventfull.

Discussion: Due to its small dimensions and infrequence, the diagnosis could be challenging even if the patient undergoes a CT scan. The presentation with clear signs of small bowel obstruction associated with a large abdominal hernia is rare and suggests a urgent surgical approach with mesh repair to avoid recurrences.

Conclusion: Even if rarely symptomatic, the Spigelian Hernia is an entity to consider in the differential diagnosis of small bowel obstruction in a virgin abdomen. Preoperative diagnosis, when available, is mandatory to guide a correct surgical approach.
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http://dx.doi.org/10.1016/j.ijscr.2019.09.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6796652PMC
September 2019

Temperature-Neutrophils-Multiple Organ Failure Grading for Complicated Intra-Abdominal Infections.

Surg Infect (Larchmt) 2020 Feb 28;21(1):69-74. Epub 2019 Aug 28.

Department of Surgery, University of L'Aquila, San Salvatore Hospital, L'Aquila, Italy.

The grading systems for intra-abdominal sepsis (IAS) are not employed commonly in clinical practice because they are too complicated or too specific. We propose to grade IAS with a simple grading system: the TNM system, which is an acronym borrowed from cancer staging, where T indicates Temperature, N indicates Neutrophils, and M indicates Multiple organ failure (MOF). The aim of this prospective observational study is to assess the predictive value of the TNM score on deaths of patients with complicated IAS. We considered 147 patients with complicated IAS. Three classes of attribute were chosen: Temperature (T), Neutrophil count (N), and MOF (M). After defining the categories T (T0-T4), N (N0-N3), and M (M0-M2), they were grouped in stages (0-IV). We analyzed specific variables for their possible relation to death: Age, gender, blood transfusion, causes of IAS, T, N, pre-operative organ failure, immunocompromised status, stage 0, I, II, III, and IV. Odds ratios were calculated in a uni-variable and multi-variable analysis. This was the distribution in classes, based on TNM stages: One patient was in stage 0; 15 patients in stage I; 47 patients in stage II; 56 patients in stage III; 28 patients in stage IV. Death occurred in 45 (30.6%) patients. The N, pre-operative organ failure, immunocompromised status, stage III-IV were potential predictors of post-operative death in uni-variable analysis. Only pre-operative organ failure and stage IV were significant independent predictors of post-operative death in multi-variable analysis. The TNM classification is an easy system that could be considered to define the death risk of patients with IAS and to compare patients with sepsis.
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http://dx.doi.org/10.1089/sur.2019.092DOI Listing
February 2020

Rare case of upper gastrointestinal bleeding: Dieulafoy' s lesion of duodenum. A case report.

Ann Med Surg (Lond) 2019 Sep 13;45:19-21. Epub 2019 Jul 13.

Department of Surgery, Val Vibrata Hospital, Teramo, Italy.

Dieulafoy's lesion is an uncommon but important cause of recurrent upper gastrointestinal bleeding. Extragastric location of Dieulafoy's lesion is rare. We report a case of haemorrhagic shock due to delafoy ulcer of the duodenum. After the failure of endoscopic haemostatic treatment, and due to the hemodynamic instability, the patient was not a candidate for transarterial embolization, the emergency surgery was needed to stop the bleeding. Using minimally invasive technique, we were able to avoid radical surgery, in critical patient would have high mortality rate. Aggressive endoscopic examinations combined with the accurate treatment endoscopic, or after the failure of this, in cases of severe hemorrhagic shock, surgical approach should be adopted when Dieulafoy-like lesion is suspected as a possible cause of upper GI haemorrhage.
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http://dx.doi.org/10.1016/j.amsu.2019.07.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6639656PMC
September 2019

Hypovolemic shock after pelvic radiotherapy. A rare combination leading to a devastating complication.

Ann Ital Chir 2019 Jun 26;8. Epub 2019 Jun 26.

Background: Radiotherapy currently plays a key role in pelvic malignancies' management. Excellent outcomes have been reported on its association with chemotherapy for the treatment of the anal carcinoma. Despite that, the combined use of chemo- and radiotherapy and the high doses administered seem to be strongly associated with early and late onset side effects.

Methods: We reported a case of a 72 years old woman, affected by anal squamous cell carcinoma. She underwent chemotherapy, and then radiotherapy, with good results.

Results: During a regular MR control, the patient developed anaphylactic reaction to Gadolinium, and after that a rectosigmoid ischemia with total necrosis of the posterior rectal wall was diagnosed and surgically treated with Hartmann procedure.

Conclusion: In our case we faced with the rapid and severe degeneration of pelvic anatomy determined by the sum of vascular alterations following hypovolemic shock and pelvic tissues alteration after radiotherapy. It seems essential not to underestimate the exponential outcome of a similar unusual combination of events.

Key Words: Anal carcinoma, Hypovolemic shock, Pelvic radiotherapy, Rectal necrosis.
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June 2019

Sporadic perivascular epithelioid cell tumor of the wall of the jejunum A case report.

Ann Ital Chir 2019 Jun 26;8. Epub 2019 Jun 26.

Background: Perivascular epithelioid cell tumors are rare mesenchymal tumors composed of histologically and immunohistochemically distinctive perivascular epithelioid cells. They are considered ubiquitous tumors and have been described in different organs, but gastro-intestinal PEComas are diseases of extreme rarity.

Methods: We report a case of a 51-year-old woman, without a medical history of tuberous sclerosis complex, affected by abdominal PEComa, adhering tightly to the jejunal loop and to the spleen.

Results: During the surgical operation, a large abdominal mass was found, and surgical resection was carried out. Definitive histologic and ultrastructural findings were consistent with PEComa.

Conclusion: Given the rarity of GI-PEComas and the lack of cases reported in the literature, we want to emphasize the importance of conducting further studies in this regard, to better describe their biological behaviour.

Key Words: Gastro-intestinal tumor, PEComa, Perivascular epithelioid cell tumors.
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June 2019

Nerve root metastasis of gastric adenocarcinoma: A case report and review of the literature.

Int J Surg Case Rep 2019 8;61:9-13. Epub 2019 Jul 8.

Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila, Italy.

Introduction: Nerve root metastasis without extension from an adjacent process has been seldom reported in case of solid tumors. We describe a case of solitary nerve root metastasis of gastric adenocarcinoma, likely due to hematogenous spread.

Case Presentation: A 75-year-old man presented with radiculopathy refractory to medical treatment. MRI and CT demonstrated a right-sided S1 nerve root mass involving the spinal ganglion in its intra-foraminal region with avid enhancement, initial erosive bone changes on sacral foramina and focal hyperaccumulation on 18F - FDG CT-PET, suspicious for metastasis. The histopathological examination confirmed a metastasis of gastric adenocarcinoma.

Discussion: A review of the current literature revealed only ten cases of hematogenous metastases to spinal nerve root ganglia; the primary lesions in those cases were an oat cell carcinoma of the lung, two cases of colonic adenocarcinoma, a case of uterine adenocarcinoma, a ductal breast carcinoma, a Ewing's sarcoma, a Renal Cell Carcinoma, a gastro-intestinal stromal tumor, a follicular thyroid carcinoma, a pulmonary adenocarcinoma.

Conclusion: In the setting of a known malignancy, a nerve root metastasis should be considered in the differential diagnosis of a nerve root mass, although it occurs very rarely.
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http://dx.doi.org/10.1016/j.ijscr.2019.07.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6625974PMC
July 2019

Indocyanine Green Fluorescent Angiography During Laparoscopic Sleeve Gastrectomy: Preliminary Results.

Obes Surg 2019 12;29(12):3786-3790

Department of General Surgery, Hospital San Salvatore L'Aquila, University of L'Aquila, L'Aquila, Italy.

Introduction: Indocyanine green (ICG) fluorescent angiography has been routinely applied for various laparoscopic procedures to evaluate the tissue blood supply. A promising branch for this technology is represented by bariatric surgery, especially to estimate the risk of gastric leak after laparoscopic sleeve gastrectomy (LSG), which seems mainly related to ischemia of the stomach.

Materials And Methods: 43 consecutive patients from January 2018 to March 2019 underwent in our institution LSG with intravenous injection of 5 ml ICG after the realization of gastric tube to evaluate the blood supply of the gastric tube.

Results: In all 43 cases, there have been no adverse events related to ICG. The vascular supply to stomach was estimated "satisfactory" along the stapled line in all cases. However, one patient showed signs and symptoms indicative of gastric leak in the fifth post-op day and diagnosis was confirmed by CT scan with Gastrografin.

Conclusions: From our preliminary data, the intraoperative view of the blood supply of the stomach does not seem to represent a prognostic factor for the risk of gastric leak, suggesting a complex multifactorial etiology (intragastric hypertension? Abnormal inflammatory response?) which needs further data to be established.
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http://dx.doi.org/10.1007/s11695-019-04085-yDOI Listing
December 2019

Short- and long-term results after laparoscopic floppy Nissen fundoplication in elderly versus non-elderly patients.

J Minim Access Surg 2020 Jul-Sep;16(3):256-263

Department of Surgery, University of L'Aquila, L'Aquila, Italy.

Background: Laparoscopic anti-reflux surgery could be of benefit in a subset of elderly patients with gastroesophageal reflux disease. However, there are few reports that have evaluated the long-term results. This study examined the effects of age on the short- and long-term (for at least 5 years) outcomes after laparoscopic Nissen fundoplication (LNF).

Patients And Methods: Patients were divided into four groups as follows: young (18-49); adult (50-69); and elderly (70-84), and very elderly (85-91). The database (recorded prospectively) included operating duration, conversion, intra- and early post-operative complication and late outcomes. Mean follow-up was 14.5 years (range 5-24 years).

Results: Five hundred and sixty-nine patients met the inclusion criteria: young n = 219 (38.4%); adult n = 248 (43.5%); elderly n = 91 (16.0%) and very elderly n = 11 (1.9%). Hiatal hernia (type I and III) was significantly less frequent in young and adult patients (P < 0.0001). The operation was significantly longer in elderly and very elderly patients (P < 0.001); the use of drains (P < 0.001) and grafts (P < 0.0001) for hiatal hernia repair was less in young and adult patients. The hospital stay, conversion (5.4%), intra-operative and early post-operative complications were not influenced by age. Dysphagia was evenly distributed among the groups. Forty-eight (8.4%) patients had recurrence: 15 in the young group (6.8%), 18 in the adult group (7.2%), 11 in the elderly group (12%) and 4 in the very elderly group (36.3%) (P < 0.0001).

Conclusions: Age does not influence short- and long-term outcomes following LNF. Control of reflux in the elderly is worse than adult patients. Therefore, ageing is a relative contraindication to LNF.
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http://dx.doi.org/10.4103/jmas.JMAS_269_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7440002PMC
April 2019

Gastric leak after laparoscopic sleeve gastrectomy: management with endoscopic double pigtail drainage. A systematic review.

Surg Obes Relat Dis 2019 08 20;15(8):1414-1419. Epub 2019 Mar 20.

Department of General Surgery, San Salvatore Hospital, L'Aquila, Italy; Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.

Gastric leak remains the main complication after sleeve gastrectomy, but there are no standardized guidelines for its treatment. Good results have been reported using endoscopic double-pigtail stent. To estimate its effectiveness, we carried out this systematic review. Eleven eligible articles were identified by searching PubMed, Embase, and Cochrane Library databases. A total of 385 patients met the inclusion criteria. The pooled proportion of successful leak closures by using double pigtail drainage was 83.41%. The proportion of successful leak closures by using double pigtail drainage by experienced operators as first-line treatment was 84.71%. Our review suggested that double-pigtail stent could be a valid approach to manage the postbariatric gastric leak, with low rate of complications and a good tolerance by patients. More high-quality studies with large samples sizes should be undertaken to better evaluate and compare the variety of techniques available.
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http://dx.doi.org/10.1016/j.soard.2019.03.019DOI Listing
August 2019

Lymphangiomatosis of the ileum with perforation: A case report and review of the literature.

Ann Med Surg (Lond) 2019 May 29;41:6-10. Epub 2019 Mar 29.

Department of Surgery, University of L'Aquila, Italy.

Lymphangiomatosis is a benign proliferation of lymph vessels. Lymphatic diseases can vary from small lymphangioma to generalized lymphangiomatosis, which is a rare condition and can have several clinical manifestations. The gastrointestinal tract may be affected, but the incidence in the intestinal wall is very low. We propose in our study a case of ileal lymphangiomatosis presenting with perforation, in which the diagnosis was made after the pathological analysis of the resected intestinal tract. Although rare and not described in the literature, intestinal lymphangiomatosis could manifest itself with acute abdomen and could be a surgical urgency. This disease should be considered when intestinal perforation is observed.
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http://dx.doi.org/10.1016/j.amsu.2019.03.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6449703PMC
May 2019

Complications of postlaparoscopic sleeve gastric resection: review of surgical technique.

Minerva Chir 2019 Jun 13;74(3):213-217. Epub 2019 Feb 13.

Department of Surgery, University of L'Aquila, L'Aquila, Italy.

Background: Laparoscopic sleeve gastrectomy (LSG) has become a very frequent procedure in bariatric surgery. Despite its simplicity, it can have serious complications. Among these, gastric leak is one of the most feared complications. Numerous intraoperative maneuvers have been suggested in an attempt to decrease the incidence of leak. In our center, we decided to study one of the intraoperative measures proposed, which consists in positioning the suture machine to 1.5 cm from His corner.

Methods: This retrospective study reported 101 cases of LSG performed in our center from 2012 to 2017. The patients were divided into two groups, with comparable anthropometric parameters and comparable inclusion criteria. In the two groups the operative technique used was the same, except for a maneuver: in the second group, attention was paid to keep a distance from the angle of at least 1.5 cm.

Results: On a total of 101 procedures performed, the overall complication rate was 4,95%. In group 1 the rate of gastric staple line leak was 6.78%. In group 2 the rate was 2.38%.

Conclusions: The analyzed surgical technique seems to decrease the risk of leak without significantly impacting weight loss, and we have noticed in our clinical experience a decrease in the incidence of fistula from the time this measure was adopted. Also the statistical analysis encourage the continuation of experimentation.
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http://dx.doi.org/10.23736/S0026-4733.19.07883-0DOI Listing
June 2019

A case of intrasplenic displacement of an endoscopic double-pigtail stent as a treatment for laparoscopic sleeve gastrectomy leak.

Int J Surg Case Rep 2018 13;53:367-369. Epub 2018 Nov 13.

Department of Surgery, University of L'Aquila, L'Aquila, Italy.

Introduction: The most frequent and severe complication after laparoscopic sleeve gastrectomy is gastric leak. Nowadays, there is no specific standard recommendation for its management, but the endoscopic placement of a double-pigtail drain across the leak has been proven to be effective and minimally invasive. Stent displacement into the abdominal cavity is not common and intrasplenic migration is even more rare.

Case Presentation: We report a case of a 49-year-old woman with intrasplenic displacement of an endoscopic double-pigtail stent as a treatment for laparoscopic sleeve gastrectomy leak.

Discussion: Pigtail drain migration involving the spleen is rare but may potentially expose the patient to the risk of parenchymal abscess or haemorrhage. Often the clinic does not indicate early this complication.

Conclusion: We underline the need for a close radiologic follow-up, regardless of clinical conditions, in all patients treated with double-pigtail drain and its early removal in case of migration.
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http://dx.doi.org/10.1016/j.ijscr.2018.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6257903PMC
November 2018

Laparoscopic Nissen fundoplication: The effects of high-concentration supplemental perioperative oxygen on the inflammatory and immune response: A randomised controlled trial.

J Minim Access Surg 2018 Jul-Sep;14(3):221-229

Department of Surgery, University of L'Aquila, L'Aquila, Italy.

Background: A number of studies have been reported on the effects of high-concentration oxygen (HCO) on cytokine synthesis, with controversial results. We assessed the effect of administration of perioperative HCO on systemic inflammatory and immune response in patients undergoing laparoscopic Nissen fundoplication (LNF).

Materials And Methods: Patients (n = 117) were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO) of 30% (n = 58) or 80% (n = 59). Administration was commenced after induction of anaesthesia and maintained for 6 h after surgery. White blood cells, peripheral lymphocytes subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-1 and IL-6 and C-reactive protein (CRP) were investigated.

Results: A significantly higher concentration of neutrophil elastase, IL-1, IL-6 and CRP was detected post-operatively in the 30% FiOgroup patients in comparison with the 80% FiOgroup (P < 0.05). A statistically significant change in HLA-DR expression was recorded post-operatively at 24 h, as a reduction of this antigen expressed on monocyte surface in patients from 30% FiOgroup; no changes were noted in 80% FiOgroup (P < 0.05).

Conclusions: This study demonstrated that perioperative HCO (80%), during LNF, can lead to a reduction in post-operative inflammatory response, and possibly, avoid post-operative immunosuppression.
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http://dx.doi.org/10.4103/jmas.JMAS_120_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6001299PMC
March 2018

Intraluminal ileal tumour after right hemicolectomy for cancer: An implantation recurrence or a new cancer? A case report.

Ann Med Surg (Lond) 2017 Nov 29;23:17-20. Epub 2017 Sep 29.

Department of Applied Clinical Science and Biotechnology, University of L'Aquila, Via Vetoio, 67100 L'Aquila, AQ, Italy.

Introduction: Extra-anastomotic intraluminal recurrence of the colon cancer after curative surgery was rarely reported but intraluminal ileal relapse has not been described to date.We report a case of intraluminal ileal tumor arising after curative right hemicolectomy that could be ascribed to an implantation of exfoliated cancer cells.

Case Report: A 71-years old man was admitted with no metastatic stenotic adenocarcinoma of the hepatic flexure and submitted, without preoperative bowel preparation, to right hemicolectomy using a "no-touch" technique. Histology showed moderately differentiated adenocarcinoma without lymph nodes involvement (pT3N0). No adjuvant therapy was prescribed. First colonoscopy three months after surgery was negative but a second endoscopic examination nine months later revealed an ileal neoplasia, presenting like an ulcer 10 cm proximally to ileocolic anastomosis. A new ileo-colic resection including past anastomosis was performed with curative intent. Pathological examination showed moderately differentiated adenocarcinoma extended to peri-visceral fat tissue with 10 tumor-free lymph nodes. (pT3N0). Six courses of Capecitabine adjuvant chemotherapy was prescribed and 32 months after second surgery, the patient is alive without disease.

Discussion: In the present case, the relatively short time from the primary surgery and the fact that recurrence occurred outside the anastomosis suggest that implantation of exfoliated malignant cells seems to be the main pathogenetic mechanism. We suppose that the high grade of primary cancer and the occlusive condition could have promoted the cancer cells reflux through the ileocecal orifice and in the transverse colon.

Conclusion: This case seems to confirm the intraluminal implanting capacity of exfoliated carcinoma cells.
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http://dx.doi.org/10.1016/j.amsu.2017.09.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5656755PMC
November 2017

Intestinal permeability changes, systemic endotoxemia, inflammatory serum markers and sepsis after Whipple's operation for carcinoma of the pancreas head.

Pancreatology 2017 Sep - Oct;17(5):839-846. Epub 2017 Jul 29.

Department of Surgery, University of L'Aquila, L'Aquila, Italy.

Pourpose: The aim was to evaluate the relationship between failure of gut barrier function, inflammatory markers and septic complications after pancreatoduodenectomy for pancreatic adenocarcinoma.

Methodology: 44 patients were enrolled in this prospective observational clinical study and underwent curative open pancreatoduodenectomy for adenocarcinoma of the head of the pancreas. All patients underwent assessment of intestinal permeability using the lactulose/manitol excretions ratios (L/M ratio), endotoxemia, IL-1β, IL-6, CRP, and elastase levels before surgery and on postoperative days 1, 3 and 7. Septic complication was defined as a specific clinical condition related to infection by bacterium, virus, or fungus in a specific organ/compartment with positive culture.

Results: Septic complications developed in 25% of patients. There were no significant differences in preoperative L/M ratio, endotoxine, CRP, IL-1β, IL-6, and elastase levels between sepsis-positive and sepsis-negative groups. All patients showed a significant increase in intestinal permeability, endotoxemia, IL-1, IL-6, CRP and elastase on the first postoperative day. At postoperative day 7, the sepsis-positive group continued to demonstrate an increase in intestinal permeability, endotoxemia and elastase; a significant difference was observed between the two groups (P = 0.02), whereas there was no significant difference in IL-1, IL-6, and CRP levels.

Conclusion: The pattern of change of intestinal permeability, systemic endotoxemia, and elastase concentration in the postoperative period is significantly higher in patients in whom sepsis develops, while the concentration of IL-1β, IL-6 and CRP do not permit to distinguish infection from inflammation.
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http://dx.doi.org/10.1016/j.pan.2017.07.190DOI Listing
June 2018