Valentina Giaccaglia

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.

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.

Minimally invasive adrenalectomy for incidentally discovered cavernous hemangioma

Cavernous hemangiomas are rare, benign, non‐functioning neoplastic lesions that often involve liver and skin. Hemangiomas of the adrenal gland are very uncommon, and usually found accidentally in otherwise asymptomatic patients. This paper reports the only case of a large cavernous hemangioma removed with transperitoneal laparoscopic adrenalectomy and reviews the literature.

Technical characteristics can make the difference in a surgical linear stapler. Or not

BACKGROUND Anastomotic leak (AL) after gastrointestinal surgery is a severe complication associated with relevant short- and long-term sequelae. Most of the anastomosis are currently performed with a surgical stapler that is required to have appropriate characteristics to guarantee good performances. The aim of our study was to evaluate, in the laboratory, pressure resistance and tensile strength of anastomosis performed with different surgical linear staplers, available in the market. MATERIALS AND METHODS We have been studying three linear staplers, with diverse cartridges and staple heights, of three different companies, used for gastrointestinal anastomosis and gastric or intestinal closure. We performed 50 anastomosis for each device, with the pertinent different cartridges, on fresh pig intestine, for a total of 350 anastomosis, then injected saline solution and recorded the pressure that provokes a leak on the staple line. There were no statistically significant differences between the mean pressure necessary to induce an AL in the various instruments (P > 0.05). For studying the tensile strength, we performed a total of 350 anastomosis with the different linear staplers on a special strong paper (Tyvek), then recorded the maximal tensile force that could open the anastomosis. RESULTS There were no statistically significant differences between the different staplers about the strength necessary to open the staple line (P > 0.05). CONCLUSIONS we demonstrated that different linear staplers of three companies available in the market give comparable anastomotic pressure resistance and tensile strength. This might suggest that small dissimilarities between different devices are not involved, at least as major parameters, in AL etiology.

Acute abdomen: Rare and unusual presentation of right colic xanthogranulomatosis

Xanthogranulomatous inflammation (XGI) is a disease of unknown origin, most frequently described in the kidney and gallbladder; its localization in the colorectal tract is extremely rare. The extension of the typical inflammatory process to the surrounding tissues may lead to misdiagnosis as cancer. We report the case of a 56-year-old woman presenting to the Emergency Department with pain, increased levels of α1 and α2 proteins and C-reactive protein (17.5 mg/dL; normal value 0-0.5), and a palpable mass, localized in the right lower quadrant of the abdomen. A computed tomography scan showed a large right cecal mass with necrotic areas, local inflammation of retroperitoneal fat, and enlargement of local lymph nodes. Because of the high suspicion of colic abscess as well as malignancy and worsening of the clinical condition, the patient underwent right colectomy after 4 d of antibiotic treatment. Pathology revealed xanthogranulomatous inflammation involving the ileocecal valve. We review the reports of large bowel tract XGI in the international literature.

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.

Re: metastasis of gallbladder adenocarcinoma to Bauhin's valve: an extremely rare cause of intestinal obstruction.

We would like to offer our experience with an unreported type of metastasis to Bauhin’s valve deriving from gallbladder adenocarcinoma as well as determining intestinal obstruction. An 83-year-old woman presented with intestinal obstruction of 2 days duration. Contrast-enhanced CT scan of the abdomen documented distended small-bowel loops and a 31 x 23 mm lesion in the right iliac fossa with distal ileal and cecal involvement (Fig. 1); additionally, a centimetric metastasis was observed in segment IV of the liver. An initial conservative management resulted successful permitting elective colonoscopy to visualize a polypoid lesion at the Bauhin’s valve (Fig. 2); biopsies were noncontributory. At this point, we decided to perform a right colectomy associated with an ultrasound-guided

Misdiagnosed esophageal perforation treated with endoscopic stent placement: a case report

Esophageal perforation has a high rate of mortality. Many strategies have been advocated for its management. Therapeutic options are surgical repair or resection, endoscopic placement of self-expandable metallic stents or, in selected cases, conservative management.We describe a case of a 75-year-old man admitted to our hospital for forceful vomiting since 24 hours. The patient was treated with endoscopic placement of a covered self expandable metallic stent. Although the late diagnosis delayed the treatment, the patient survived the usually fatal condition. The stent removal was performed 8 weeks after implantation.Immediate and correct diagnosis are the key elements in improving survival of patients with esophageal perforation. This has to be associated to the selection of the most appropriate treatment. Implantation of covered self-expandable metallic stents in compromised patients with esophageal perforation is a safe and feasible alternative to operative treatment.

Non-operative management for ruptured splenule in haemodynamically stable patients previously splenectomized

A 33-year-old motorcyclist knocked down by a car was referred to our casualty. Thirteen years before, he was splenectomized after a similar trauma and an accessory spleen was detected in the left hypochondriac region on a subsequent computed tomography (CT) scan. At arrival in casualty, vital signs and haemogram were unremarkable: contrast-enhanced CT of the abdomen showed that the accessory spleen (9 cm in diameter) was fractured with foci of active intraparenchymal haemorrhage (Fig. 1). Repeated CT at 6 h documented persisting active bleeding and pelvic haemoperitoneum. Due to haemodynamic and haemogram stability, we opted for a close observation in intensive care unit deferring embolization or intervention to a clinical worsening which did not occur. The patient did well after the trauma and was home in 7 days without any haemotransfusion. Accessory spleen (also known as splenule or splenunculus) occurs in 10 to 30% of population as reported by autopsy studies. It develops during the fifth week of embryonic life from the failure of fusion of splenic buds: for this reason it can be single or multiple. The (a)