Search

Background: COVID-19 lockdown restrictions in conjunction with the pervasive hospital fear endured by the vast majority of the population played a fundamental role in discouraging access to emergency departments (EDs). We aimed at investigating whether and how the COVID-19 outbreak limited the access to ED and affected urgent surgical activities during and immediately after the 2-month pandemic-related national lockdown., Methods: Data regarding patients who accessed to the surgical ED were retrospectively collected. Analyzed time-periods included: "pre-COVID-19 era," "COVID-19 era" considered as the period of full national lockdown and "post-COVID-19 era" after easing of lockdown measures. Consecutive emergency surgical procedures and ED admissions before, during and after COVID-19-lockdown were retrieved and analyzed., Results: There was a significant decrease in overall ED admissions and in all-specialty surgical consultations (P<0.01) throughout the outbreak. Once national lockdown was eased, we recorded a subsequent rebound 5-fold rise of emergency surgical procedures compared to COVID-19 group (P=0.011). Time-to-surgery was significantly greater in "COVID-19 era" and "post-COVID-19 era" compared to "pre-COVID-19" group (22.56±4.78, 75.99±15.89 and 16.73±1.76 hours, respectively) (P<0.01). A raised incidence of postoperative complications emerged in the "COVID-19 era" group (37.5%) compared to pre- and post-COVID groups (9.1% and 12.5%, respectively; P<0.001). Mortality rate in the "COVID-19 era" was 31.3% and 7.5% in "post-COVID-19" group (<0.0001)., Conclusions: This study demonstrates the major reduction of emergency surgical procedures and overall, ED admissions caused by COVID-19 pandemic. The raised rate of postoperative complications and mortality might be likely due to the superior severity of surgical conditions observed in the "COVID-19 era" subjects together with a probable deferred pursuit of medical attention.

The outbreak of Coronavirus disease 2019 (COVID-19) worldwide had evidenced the opportunity to increase the interaction between specialist and primary care physician (PCP). COVID 19, started in December 2019 in China, has been considered a public health emergency by the Department of Health and Human Services and, now, it is a pandemic disease with worldwide diffusion. The COVID-19 crisis permits to increase the role of telemedicine as a tool for the delivery of health care services at distance and to slow down the virus diffusion. This technology is cheap and easy to use but it is limited by governmental licensing restrictions, reimbursement barriers, lesser extent of infrastructure and difficulties related to the change. During COVID-19 epidemy, telemedicine is safe, low cost and-permits to treat urgent and routine specialist cases without human proximity and contact which would spread infection, particularly to the elderly and immunocompromised patients. In COVID-19 era, the goal of PCP is to reduce travels and visits in specialized center for liver disease patients. A strict collaboration between specialized hepatologist and PCP is needed.

Background: Laparoscopic cholecystectomy represents the gold standard technique for the treatment of lithiasic gallbladder disease. Although it has many advantages, laparoscopic cholecystectomy is not risk-free and in special situations there is a need for conversion into an open procedure, in order to minimize postoperative complications and to complete the procedure safely. The aim of this study was to identify factors that can predict the conversion to open cholecystectomy., Methods: We analyzed 1323 patients undergoing laparoscopic cholecystectomy over the last five years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome. Among these, 116 patients (8.7%) were converted into laparotomic cholecystectomy. Clinical, demographic, surgical and pathological data from these patients were included in a prospective database. A univariate analysis was performed followed by a multivariate logistic regression., Results: On univariate analysis, the factors significantly correlated with conversion to open were the ASA score higher than 3 and the comorbidity, specifically cardiovascular disease, diabetes and chronic renal failure (P<0.001). Patients with a higher mean age had a higher risk of conversion to open (61.9±17.1 vs. 54.1±15.2, P<0.001). Previous abdominal surgery and previous episodes of cholecystitis and/or pancreatitis were not statistically significant factors for conversion. There were four deaths in the group of converted patients and two in the laparoscopic group (P<0.001). Operative morbility was higher in the conversion group (22% versus 8%, P<0.001). Multivariate analysis showed that the factors significantly correlated to conversion were: age <65 years old (P=0.031 OR: 1.6), ASA score 3-4 (P=0.013, OR:1.8), history of ERCP (P=0.16 OR:1.7), emergency procedure (P=0.011, OR:1.7); CRP higher than 0,5 (P<0.001, OR:3.3), acute cholecystitis (P<0.001, OR:1.4). Further multivariate analysis of morbidity, postoperative mortality and home discharge showed that conversion had a significant influence on overall post-operative complications (P=0.011, OR:2.01), while mortality (P=0.143) and discharge at home were less statistically influenced., Conclusions: Our results show that most of the independent risk factors for conversion cannot be modified by delaying surgery. Many factors reported in the literature did not significantly impact conversion rates in our results.

Background: The number of surgical operations in elderly patients is increasing due to the aging demographics of western populations. The aim of the present study was to investigate the peri-operative outcome of octogenarian patients undergoing cholecystectomy for acute cholecystitis., Methods: We performed a retrospective analysis including all patients who underwent cholecystectomy for acute cholecystitis from January 2013 to December 2017. Records were collected prospectively from two centers: 1) Unit of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum University, Bologna; 2) "Advanced Surgical Technologies" Department of Surgical Sciences, Umberto I University Hospital, La Sapienza University, Rome. Patients were divided by age (≥ or <80 years) and peri-operative outcomes were compared., Results: During the study period, 464 patients were operated for acute cholecystitis in the two centers. Sixty-three (14%) patients were octogenarians (group 1) and median age was 84.8±3.9 years. Four hundred and one patients (86%) were younger than 80 years (group 2) with median age of 55.3±15.3 years. Forty-four per cent of group-1 patients underwent laparoscopic cholecystectomy versus 81% of the younger group (P<0.01). Elderly patients had a higher percentage of overall complications (25% vs. 9%; P=0.03) and a longer median postoperative length of stay (7.2±6.8 vs. 4.6±7.7; P=0.04). Overall mortality was 1%: two patients died in group-1 and one in group-2 (P=0.50). However, on multivariate analysis age older than 80 years was not found to be an independent risk factor for postoperative morbidity and mortality., Conclusions: The results of this study suggest that cholecystectomy for acute cholecystitis in octogenarians is a relatively safe procedure with an acceptable risk of complications and a postoperative hospital stay comparable to younger ones.

The association between gluten related disorders and psychiatric diseases has been firmly demonstrated. Non-celiac gluten sensitivity (NCGS) is a syndrome diagnosed in patients responsive to gluten-free diet after ruling out celiac disease and wheat allergy. The pathogenesis of neuro-psychiatric disorders in NCGS is unclear. An association between gluten and schizophrenia was described for the first time in 1950 by Bender et al. In the 1950's, Dicke noted that gluten-free diet improved mood in celiac patients. In 1970, Goldberg et al., in a study of 80 celiac patients, found that 34% of them showed minor affective disorders. Bipolar disorder patients show an increase of blood anti gliadin deamidated antibodies (IgG). The effect of diet and nutrition on autistic spectrum disorders has been investigated in the last two decades, particularly focusing on the symptoms of hyperactivity and attention. Toxoplasma gondii and other neurotropic pathogens as Influenzavirus and Coronavirus may be associated with mood disorders, probably secondary to an increased intestinal permeability. Abnormalities of host-microbiota interactions or of gut-microbiota composition have been associated with central nervous system disorders, such as autism, anxiety, depression and the integrity of intestinal microbiota may be considered a potential therapeutic goal to treat these conditions.

Celiac disease (CD) determines neurologic manifestations in 10% of all CD patients. We describe the most common clinical manifestations as cerebellar ataxia, gluten encephalopathy, multiple sclerosis, peripheral neuropathies, sensorineural hearing loss, epilepsy, headache, depression, cognitive deficiencies and other less described clinical conditions. Our aim is to perform, as more as possible, a review about the most recent update on the topics in international literature. It is important to consider clinical neurological manifestations in celiac patients and to research these conditions also in the follow-up because they may start also one year after the start of gluten free diet (GFD) as peripheral neuropathy. The association with autism is analysed and possible new association with non-celiac gluten sensitivity (NCGS) are considered.

Celiac disease (CD) and inflammatory bowel disease (IBD), such as Crohn's disease (CrD) and ulcerative colitis (UC), are chronic inflammatory condition of the gastro-intestinal tract. The prevalence of IBD in celiac patients has been reported as 5-10 times higher than in the general population. The possibility of the presence of CD in IBD should be considered in IBD patients with long-term iron deficiency anemia (IDA) not responsive to iron supplementation. Non-celiac gluten sensitivity (NCGS) is characterized by intestinal and extra intestinal symptoms due to the ingestion of gluten-containing food in subject without CD and/or wheat allergy. Patients with Crohn's disease and SR-NCGS were more significantly affected by joint pains compared to UC patients (50% versus 11.1%). In Crohn's patients, a higher percentage of fatigue (50% versus 38.9%) and headache (27.3% versus 22.2%) was evident. For the association between NCGS and IBD new studies are warranted and, at this moment, a gluten free diet (GFD) may be useful more in CrD than in UC.

Recent clinical experience with the use of thalidomide in inflammatory bowel disease is the focus of this article. Although widely used in Crohn's disease, thalidomide therapy in patients with ulcerative colitis, children with Crohn's disease, as well as patients with Crohn's disease associated with upper gastrointestinal and genital tract involvement have been occasionally reported.

The incidence of gastrointestinal involvement is relatively observed in patients with vasculitis processes. Vasculitis can be primary (necrotising or hypersensitivity) or secondary to another primary disease. Gastrointestinal involvement is present in up to 50% of the various forms of systemic vasculitis. Primary or secondary vasculitic process, according to the classification in necrotizing and hypersensitivity vasculitis, are described in this paper. A review of the literature on the the subject is also presented.

Unlabelled: Mineral trioxide aggregate (MTA), composed mainly of tricalcic silicate, tricalcic alluminate, bismuth oxide, is a particular endodontic cement. It is made of hydrophilic fine particles that harden in the presence of dampness or blood. It is biocompatible, radiopaque and it is harder to infiltrate, compared to classic materials for root filling such as amalgam, cements, Super-EBA, and IRM. and SEM studies of sections and copies in resin of root neoapices filled with amalgam, IRM, Super-EBA and MTA, as well as tests of microinfiltration have shown that MTA has excellent sealing capacities. It requires a working time of about 5 min and a hardening time that varies from 2 h and 45 min to 4 h according to the density of the air entrapped during mixing and the dampness of the receiving site. The long hardening time reduces internal tensions and the incidence of marginal infiltration, but it forces to definitively fill the tooth in the following sitting, with an interval of at least 3 days from the MTA application. Clinical experience shows how MTA is a material of choice in cases not only of endodontic surgery, apicectomy and retrograde filling but also in the sealing filling of perforations of the pulp chamber and of the root, stripping, internal reabsorptions, readaptations, lacerations, and apical transports. It has been used with success also in direct cappings and in apexifications instead of calcium hydroxide, leading to quicker therapies and more predictable, Results: The authors outline the operative phases of the different treatments proposed, make a survey of the most important studies published so far and hope that a new sealing cement with more reduced hardening times will soon be available.

At present, laparoscopic splenectomy (LS) is mostly indicated in hematologic benign diseases, and in case of normal size spleen it is considered the gold standard. The technique is under a continuous evolution and several studies have demonstrated feasibility and safety of laparoscopic approach also in case of massive splenomegaly, malignant diseases and even in the treatment of selected cases traumatic lesions. LS is an advanced surgical procedure that requires a management of a full trained team involved in the preoperative preparation, surgical strategy and postoperative care. A fully comprehension of the impact of the surgical strategy is needed to plan the treatment of diseases that often are managed in a multidisciplinary setting. Indications and contraindications to surgery does not differ significantly from open traditional splenectomy, but the nature of the disease and the volume of the spleen can greatly influence the operation. A preoperative study with definition of these parameters along with a standard preparation to surgery is required. Over the years the technique has been developed and adapted to respond to emergent necessities related to those parameters. Anterior, semilateral, later and hand assisted approaches offer advantages and drawbacks that should be weighed in each case. They depend on surgeons preferences but most of the time are related to the preoperative studies, even when new surgical tools (i.e. harmonic scalpel and radiofrequency). No randomized, prospective trials have been conducted, however several studies with strong evidence have shown that less surgical trauma, intraoperative blood loss, early hospital discharge, rapid return to normal activities and better cosmesis can be obtained with a laparoscopic approach.

Background: Since an inverse relationship between percutaneous coronary angioplasty (PTCA) case-load and in-hospital major adverse cardiac events (MACE) exists, we intended to evaluate the performance of low-volume PTCA operators, during the first year of our interventional program, by applying the more accurate index represented by the MACE rate within the first month., Methods: The data relative to both the PTCA procedure and the control visit 3-4 weeks later, were retrospectively reviewed. Death, myocardial infarction and need for revascularization were the end-points evaluated, both globally and with respect to the individual operators., Results: During 1999, 61 consecutive patients (53M, 8F; mean age: 59.9+/-10.4 years) were treated by two full-trained operators. Stable angina was the indication in 75% of cases. Comorbidities as diabetes and prior revascularization, were present in 16 and 5% of cases, respectively. Multivessel procedures were performed in 33% of cases, with a total number of lesions of 84 (77% A/B1 type). Stents were implanted in 70% of cases, as a bail-out in 12%. Procedural success rate was 93%. Overall one-month MACE rate was 3.3%, accounted for by 1 in-hospital emergency coronary surgery occurred to operator 1 (3.6% one-month MACE rate) and 1 elective coronary operation performed in a stable patient previously treated by operator 2 (3% one-month MACE rate)., Conclusions: PTCA performed in a low-volume center by low-volume operators is not necessarily associated with a poor outcome, provided that adequate selection of low-risk cases is accomplished. Although only 52% of the Italian centers met in 1999 the recommended volume standards, reaching optimal case-load should anyway be pursued. Some time should however be conceded, provided that close monitoring of one-month MACE rate shows adequate performance of both the institution and the operators.

We described a rare case of hypocalcemia whit tetanic symptoms. This condition of our patient could be avoided if some symptoms, present from many years, were diagnosed as factors related to coeliac disease, anemia was present from many years and it was more important during four pregnancies. The appearance of diffuse bone pain from two years is correlated to a metabolic osteopathy due to coeliac disease. Unexplained increase of liver enzymes is an expression of coeliac disease. We stress the importance to always consider extra-intestinal manifestation of coeliac disease in every patients, because this disease has an high incidence (1 in 200 people). Our patient could had important clinical advantages, if his disease was diagnosed by extra-intestinal alterations (anaemia, bone pain and increased blood levels of liver enzymes in our patient). Coeliac disease must be researched in every different and particular clinical and sub-clinical manifestation; in 65% of all cases, the patients with coeliac disease haven't gastrointestinal symptoms.

Background, Materials and Methods: To compare the relative use of verapamil and beta-blockers, which have shown comparable efficacy in reducing mortality and reinfarction rates in selected patients with myocardial infarction (MI), we retrospectively evaluated the ongoing treatment at the time of the pre-discharge evaluation in 221 consecutive patients (167 males and 54 females; mean age: 62.3 +/- 10.8 years) discharged alive in 1994 from our Hospital with the diagnosis of Q-wave MI., Results: The examination of the computerized files of our central database, showed that verapamil was administered (as a monotherapy or in association) to 4% of the patients, compared to 34% of beta-blockers. The choice between the two drugs appeared not to be influenced by age (62 +/- 11 vs 57 +/- 8 years), anterior (70% vs 57%) or inferior (30% vs 40%) MI location or echocardiographic left ventricular ejection fraction (50.2 +/- 10% vs 52.3 +/- 11%), which were comparable in both groups. On the other hand, beta-blockers were used significantly more often (52% vs 10%; p < 0.05) in the presence of hypertension, while verapamil was preferred (although statistical significance was not reached) in patients with contraindications to beta-blockers, such as chronic obstructive lung disease or peripheral artery disease (20% vs 9% and 10% vs 4%; p = ns, respectively)., Conclusions: In conclusion, our study gives, for the first time, an estimate of the real use of verapamil in patients with MI, confirming, in keeping with the indications in the literature, that its administration is limited and essentially reserved to patients with contraindications to beta-blockers. A wider use of verapamil (and even more of beta-blockers) would be however hoped for, due to the relevant number of patients (62% of our population) treated with drugs, such as diltiazem, dihydropyridines or nitrates, for which a conclusive demonstration of efficacy on major clinical end-points are lacking.

Endoscopic intubation is a popular palliative method to resolve immediately malignant dysphagia. However, the complication rate is still high. Between 1978 and 1993, at the Division of Diagnostic and Surgical Endoscopy of Istituto Nazionale Tumori in Milan, 305 patients suffering from malignant dysphagia, were endoscopically treated by insertion of an endoprosthesis. We report the analysis of data regarding our complication rate, compared with the literature, and our experience in preventing managing complications related to this endoscopic procedure.

Between 1974 and 1992, at the Department of Diagnostic and Surgical Endoscopy of Istituto Nazionale Tumori, in Milan, 27 patients with resected stomach and suffering from epithelial polyps of the gastric stump (10 lesions) and/or anastomosis (25 lesions), were endoscopically treated using electroresection (13 cases), electrocoagulation (2 cases), combined methods (electroresection plus Nd:YAG photocoagulation) (1 case) and biopsy forceps (19 cases). Complications occurred in 4 cases and consisted of hemorrhage. Seven patients developed 15 recurrences. Endoscopic treatment of polyps in patients with resected stomach is a safe and effective treatment, considering the low rate of complication.

Carcinoids are the most common endocrine tumours, and arise from a multipotential primitive stem cell; the gastric location represents 2% of all carcinoids. From 1979 to 1992 at the Endoscopy Division of Istituto Nazionale Tumori, Milan, 2 patients suffering from single gastric carcinoid were endoscopically treated by electro-resection. No complication occurred during the treatment; 2 year- and 5-year-follow-up was performed in these patients, and no recurrence are observed. Surgical treatment represents the therapy of choice for gastric carcinoids, but endoscopic resection can represent an alternative in selected cases (lesions less than 1 cm or carcinoids with multicentric growth). Endoscopy can be used also in patients at high surgical risk.

Until 1970 endoscopy of the digestive tract was the only diagnostic method available. After this date, the introduction of endoscopic polypectomy enabled patients affected by these lesions to be treated, and at the same time considerably reduced their length of stay in hospital. The paper reports the results of 346 gastric polypectomies performed in 187 patients from 1974 to the present.

The efficacy and the tolerance of a polyene macrolide, mepartricin (SPA-S-160), able to interfere with intestinal absorption of cholesterol, were evaluated on 50 patients with primary hyperlipemia. Administration of 3 tablets/die for 30 days caused a significant decrease (P less than 0.01) in the lipid values, which, further controlled 30 days following treatment, proved to have remained lower than those observed at the beginning of the study.

Radioimmunologically determined digoxin and beta methyl digoxin values were the same in cardiopaths with and without clinical and instrumental changes referable to chronic cirrhosis or hepatitis. Lower values, however, were noted when gastroenteric disturbances were present. This was especially true of beta methyl digoxin in subjects with hyperkinetic-hyperchlorhydric syndromes due to depressed gastric pH, with a consequent inhibition of beta methyl digoxin absorption, presumably caused by lability of the molecule as a result of methylation of the terminal digitoxose group.

A "cross over" study was carried out in a group of 22 subjects with prostatic hypertrophy in different stages, first treated with chloroformic extract of Pygeum Africanum (4 capsules/die for 30 days) and afterwards, when the symptoms reappeared, with mepartricin (3 gastroresistant tablets of 50,000 U. each/die for 30 days). Both substances proved to be active against the urinary symptomatology; however the polyene induced a significant decrease in the prostate size (evaluated by cystography), justifying the 77% of "excellent" results against the 13% obtained with the reference drug.