Pier Federico Salvi

Procalcitonin Reveals Early Dehiscence in Colorectal Surgery: The PREDICS Study.

Objectives:We designed a multicentric, observational study to test if Procalcitonin (PCT) might be an early and reliable marker of anastomotic leak (AL) after colorectal surgery (ClinicalTrials.govIdentifier:NCT01817647). Background:Procalcitonin is a biomarker used to monitor bacterial infections and guide antibiotic therapy. Anastomotic leak after colorectal surgery is a severe complication associated with relevant short and long-term sequelae. Methods:Between January 2013 and September 2014, 504 patients underwent colorectal surgery, for malignant colorectal diseases, in elective setting. White blood count (WBC), C-reactive protein (CRP) and PCT levels were measured in 3rd and 5th postoperative day (POD). AL and all postoperative complications were recorded. Results:We registered 28 (5.6%) anastomotic leaks. Specificity and negative predictive value for AL with PCT less than 2.7 and 2.3 ng/mL were, respectively, 91.7% and 96.9% in 3rd POD and 93% and 98.3% in 5th POD. Receiver operating characteristic curve for biomarkers shows that in 3rd POD, PCT and CRP have similar area under the curve (AUC) (0.775 vs 0.772), both better than WBC (0.601); in 5th POD, PCT has a better AUC than CRP and WBC (0.862 vs 0.806 vs 0.611). Measuring together PCT and CRP significantly improves AL diagnosis in 5th POD (AUC: 0.901). Conclusions:PCT and CRP demonstrated to have a good negative predictive value for AL, both in 3rd and in 5th POD. Low levels of PCT, together with low CRP values, seem to be early and reliable markers of AL after colorectal surgery. These biomarkers might be safely added as additional criteria of discharge protocols after colorectal surgery.

Neurectomy to Prevent Persistent Pain after Inguinal Herniorraphy: A Prospective Study Using Objective Criteria to Assess Pain

BackgroundAlthough tension-free mesh repair has markedly improved the outcome of inguinal hernia surgery, it has only minimally reduced the incidence of persistent postoperative pain. The pathogenesis of this complication and treatment remain unclear.Study designIn order to objectively assess whether iliohypogastric neurectomy reduces the incidence and intensity of persistent postoperative pain, we prospectively studied 100 male patients with bilateral inguinal hernia who underwent tension-free surgical repair, combined with iliohypogastric neurectomy on the right side alone. Pain was evaluated postoperatively on days 1 and 7 and at 1 and 2 years by means of a visual analog scale. Patients were given a questionnaire including coded terms for describing pain. These terms were designed to compare pain on the neurectomized and non-neurectomized sides and assess altered sensation (hypoesthesia and paresthesia) on both sides.ResultsThere were differences in the incidence and intensity of pain between the neurectomized and non-neurectomized sides, though these differences were not significant. Individual patient assessment showed that from postoperative day 7 onward patients had on average less pain on the neurectomized side.Pain reduction was more prominent in patients who scored 4 or more on the visual analog scale. No significant difference was found in the incidence of sensory alterations between the two sides. Two years after inguinal hernia repair, only one of the 100 patients studied still had persistent pain (>4 on the visual analog scale); this pain was on the non-neurectomized side.ConclusionsOur prospective data do not reach statistical significance to claim that iliohypogastric neurectomy reduces the incidence and intensity of persistent postoperative pain after tension-free inguinal hernioplasty. Studies on larger patient samples are warranted to provide definitive, statistically supported conclusions.

Malignant peripheral neuroectodermal tumor (MPNET) of the kidney

AbstractBackground: Malignant peripheral neuroectodermal tumors (MPNETs) are primitive neuroblastic tumors that arise, unlike neuroblastomas, outside the autonomic nervous system. A renal origin has been described in very few cases. Case report: We report the case of a young male patient with a large MPNET of the right kidney, studied with ultrasound and computed tomography before surgical resection. The main radiologic features, the microscopic appearance and the typical immunohistochemical findings, are described and discussed.

Procalcitonin, as an early biomarker of colorectal anastomotic leak, facilitates enhanced recovery after surgery

PURPOSE Procalcitonin (PCT) is a biomarker used to help sepsis diagnosing and monitoring and guide antibiotic therapy. Anastomotic leak (AL) after colorectal surgery is a severe complication associated with relevant short- and long-term sequelae. The aim of our study is to assess the predictive value of PCT levels to early diagnose AL after colorectal surgery. METHODS Between September 2011 and September 2012, a series of 99 patients underwent colorectal surgery in our institution. In all cases, white blood cell (WBC) count, C-reactive protein (CRP), and PCT levels were measured in first, third, and fifth postoperative day (POD). Anastomotic leaks and all other postoperative complications were recorded. RESULTS We registered 7 ALs (7.1%). Decreased PCT levels had a significant negative predictive value (NPV) for AL in third and fifth POD (96.7% and 96.7%, respectively), compared with CRP and WBC. The best diagnostic performance was obtained with the combination of PCT and CRP measurements in third and fifth POD (area under the curve, 0.87 and 0.94, respectively). In 5th POD, PCT improves diagnosis, but not in a statistically significant way (area under the curve, 0.86). CONCLUSIONS Compared with more established biochemical values such as CRP and WBC, PCT is an earlier, more sensitive, and reliable marker of AL. Increased PCT levels in early PODs after colorectal surgery may provide a more effective way to detect AL, before clinical symptoms appear. Moreover, normal PCT values might be also a useful marker to facilitate a safe and early discharge of selected patients after colorectal surgery.

A large porocarcinoma of perineal region: MR findings and review of the literature

We present the case of a 54-year-old woman affected by a large perineal region eccrine porocarcinoma, with a wide local invasion. We discuss the clinical presentation and the imaging findings and review the literature.

Different characteristics of circular staplers make the difference in anastomotic tensile strength

Anastomotic leak after gastrointestinal surgery is a severe complication associated with relevant short and long-term sequelae. Most of the anastomoses are currently performed with a surgical stapler that is required to have appropriate characteristics in order to guarantee good performances. The aim of our study was to evaluate, ex vivo, pressure resistance and tensile strength of anastomosis performed with different circular staplers available in the market. We studied 7 circular staplers of 3 different companies, 3 of them used for gastrointestinal anastomosis and 4 staplers for hemorrhoidal prolapse excision. A total of 350 anastomoses, 50 for each of the 7 staplers, were performed using healthy pig fresh intestine, then injected saline solution and recorded the leaking pressure. There were no statistically significant differences between the mean pressure necessary to induce an anastomotic leak in the various instruments (p>0.05). For studying tensile strength, we performed a total of 350 anastomoses with 7 different circular staplers on a special strong paper (Tyvek), and then recorded the maximal tensile force that could open the anastomosis. There were statistically significant differences between one brand stapler vs other 2 companies staplers about the strength necessary to open the staple line (p<0.05). In conclusion, we demonstrated that different circular staplers of three companies available in the market give comparable anastomotic pressure resistance but different tensile strengths. This is probably due to different technical characteristics.

CRP Predicts Safe Patient Discharge after Colorectal Surgery: Reply.

Reply: We would like to thank Aurelién Duprè, Johan Gagniér, Heloı̈se Samba, Michel Rivoire, and Karem Slim for their comments about our article ‘‘Procalcitonin Reveals Early Dehiscence in Colorectal Surgery: The PREDICS Study.’’ It is very rewarding to realize that this paper is stimulating so many observations, this means that we are talking about an interesting topic. Thank you for underlining that PREDICS is a large prospective observational study, involving 3 high-volume colorectal centers in Italy. It is to note that we described study methods in our first preliminary paper; anyway, we are glad to share with you that sample size was calculated for a difference of at least 10% between the area under the receiver operating characteristics (ROC) curves (AUCs) of C-reactive protein (CRP) and procalcitonin (PCT). In the pilot study, an AUC of 0.884 was observed for PCT at third postoperative day and used for the calculation. The prevalence of anastomotic leakage was assumed to be 14% according to the preliminary study, but was much lower in the PREDICS study data (5.6%). Total number of patients to include was estimated to be 441. The study was designed to have 80% power with an alpha error of 0.05. Regarding strengthening the reporting of observational studies in epidemiology checklist, we decided not to publish it because we consider it a useful tool only during study design; anyway, in the ‘‘Materials and methods’’ section, we carefully described all study characteristics (inclusion and exclusion criteria, variables reported in the database, and statistical analysis). Positive and negative likelihood ratio (PLR and NLR) for PCT in third and fifth postoperative days (PODs) are, respectively: 7.14 and 0.44, and 9.9 and 0.33. For CRP, PLR and NLR in third POD are 3.26 and 0.50, and in fifth POD are 5.28 and 0.30, respectively. According to these results, usefulness of procalcitonin both in third and fifth POD is greater than CRP, confirming the results previously shown in our article with ROC curves. Therefore, according to PREDICS outcomes, together with this LR analysis, we keep stating that PCTand CRP could be usefully added as a diagnostic tool in early diagnosis of anastomotic leak (AL) in patients undergoing colorectal surgery for cancer. It should not absolutely be a fight between the 2 biomarkers, but a fight for better patient care. So, because adding PCT to CRP in fifth POD enhances AL diagnosis in a statistically significant way, we are proud to keep stating that this advantage is worth for patients’ life. In fact, if the patient is discharged earlier and will do well at home, we save money; on the contrary, if AL is diagnosed early, it is possible to avoid sepsis and late reoperation, and try to pursue medical therapy saving money again, and—most important—avoiding longer hospital stay and worsening oncological outcomes. We are all currently using tremendously expensive technologies in the operating room for laparoscopy and robotic surgery, and nobody is questioning this huge amount of money because it improves patient outcomes. Why should we then discuss about 20 Euros more or less (10 Euro for each PCT measurement) when patients’ quality of life can be significantly improved? The authors are stating, citing their own work, that AL diagnosis is difficult, and we absolutely agree to this conclusion. For this reason, further research in this field is more than welcome to give additional help to the clinician and guide further diagnostic and therapeutic steps when biomarker levels are high. Using biomarkers will never replace the surgeon for anastomotic leak diagnosis, but is a good help we should definitely accept to use.

Self-expandable Metallic Stents in Pregnant Patients with Obstructing Colorectal Cancer

We applaud Lamazza and associates [1] for their exhaustive and didactic study on self-expandable metallic stents (SEMS) employed in patients with stage IV obstructing colorectal cancer (CRC). In particular, we appreciated the following topics: the higher feasibility, expedience, and safety of endoscopic stenting by passing the guide wire under direct vision (using a pediatric nasogastroscope) versus a blind positioning technique, its undoubtedly more positive psychoemotional effect on patients in comparison with a diverting colostomy, the need of surveillance for patients with SEMS in order to promptly recognize and profitably treat the obstruction secondary to fecal impaction, tumor ingrowth within the stent or its dislodgement with possible bleeding or perforation. As for us, we are interested in exploring another field of application of SEMS, which is represented by its placement in pregnant patients affected by obstructing colorectal cancer, and we are looking forward to knowing their opinion about that. Recently, in fact, we had to choose between SEMS placement or diverting colostomy for a secondipara 32-year-old patient diagnosed as having a stage IV obstructing colorectal adenocarcinoma in the early postpartum period. After water-soluble enema showed complete stenosis at the rectosigmoid junction, we thought endoscopic stenting a procedure too hazardous to perform and instead performed a colostomy. As of this writing, the patient is receiving a first-line chemotherapy regimen with FOLFOX plus cetuximab while she waits for elective tumor resection. Colorectal cancer complicating pregnancy is a rare disease, with a reported incidence of 0.002 %. Such a condition poses to medical personnel a plethora of delicate problems to address and complex challenges to solve. Ensuring the physical well-being of both mother and fetus is not always possible, and every decision should be dictated by ethical principles respecting psychological, religious, and medico-legal aspects of the case. The task is rendered even more difficult by the absence of cancer or drug trials that include pregnant patients; thus there is no high-grade evidence. Curing the mother from cancer as soon as possible through surgery and chemotherapy performed during pregnancy, enabling fetal lung maturity and an uneventful delivery, assessing the appropriate route of delivery and the timing of CRC resection represent the main issues surrounding CRC in pregnancy [2]. Large bowel obstruction due to CRC in pregnancy, although infrequent, comprises another dreaded event further complicating the aforementioned scenario. Traditional methods described for mechanical decompression in pregnancy include emergency colostomy, labor induction followed by postpartum CRC resection, and conservative management with total parenteral nutrition [3, 4]. The first and hitherto sole case of colorectal SEMS placement in a pregnant woman with malignant symptomatic large-bowel obstruction was reported in 2011 by Healey et al. [5]: in brief, a 29-year-old woman at 30 weeks’ gestation with a diagnosis of T4 obstructing adenocarcinoma of the splenic flexure was initially managed with a successful stenting under fluoroscopic control enabling resolution of the obstruction, fetal lung maturity, delivery of a healthy neonate, and definitive surgery without stoma. We think this kind of release should be always considered when approaching a pregnant woman with symptomatic obstructive CRC. E. Virgilio (&) P. F. Salvi G. Balducci Department of Emergency Surgery, Faculty of Medicine and Psychology, Hospital St. Andrea, University of Rome ‘‘La Sapienza’’, via di Grottarossa 1035-39, 00189 Rome, Italy e-mail: aresedo1992@yahoo.it