Intra-abdominal infections (IAIs) continue to be an important cause of morbidity and mortality worldwide. The optimal management of patients with IAIs relies on early and accurate diagnosis, prompt and adequate source control, appropriate antimicrobial therapy based on the PK/PD principles, as well as hemodynamic support with intravenous fluids and vasopressors in critically ill patients. This narrative review aims to suggest five basic factors which should always be considered when assessing patients with IAIs to provide the most adequate treatment. These factors include the anatomical extent of the infection, the origin of the infection, the patient’s clinical status, the suspected pathogens and their resistance profiles, and immune competence. The continuous assessment of these elements is essential in managing complicated IAIs.

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

1.1. Introduction Postinflammatory polyps (PIPs) are non-neoplastic lesions originating from the mucosa after repeated periods of inflammation and ulceration connected with excessive healing processes. This pattern is usually associated with Inflammatory Bowel Diseases (IBD), but rarely they can be related to different clinical conditions. PIPs can be classified into: localized, multiple, giant, generalized and filiform polyposis (FP). FP is characterized by numerous finger‑like inflammatory polyps, lined by normal colonic mucosa. If they reach up to 100 mm forming bridges and tumor-like mass, they can be defined Giant Polyposis (GP). To date, FP has not the tumoral transforming potentiality. 1.2. Results The first presented case is a 52-year-old man with a past clinical history of Ulcerative Colitis (UC) who underwent rectosigmoidoscopy for distal sigmoid obstruction and an Hartmann’s procedure was performed; the histological findings suggested a pattern consistent with an active fase of UC with a lumen obstruent FP. The other patient is a 40-year-old man who suffered from colonic substenotic episodes; the colonscopy revealed an increase in number and dimension of mucosal polyps with bridge formation. The patient underwent resection of ileum and recto-sigmoid junction with an ileocolic anastomosis T-T; the surgical specimen showed a large polypous tumor-like mass with finger-like projections with non-specific inflammatory changes and without epithelial dysplasia or neoplastic lesion. 1.3. Conclusions This short case series points out how eterogenous the presentation of FP could be: there is no certain link between IBD and FP; in addiction, these polyps can form in a generalized condition of bowel inflammation.

Antimicrobial resistance (AMR) is a phenomenon resulting from the natural evolution of microbes. Nonetheless, human activities accelerate the pace at which microorganisms develop and spread resistance. AMR is a complex and multidimensional problem, threatening not only human and animal health, but also regional, national, and global security, and the economy. Inappropriate use of antibiotics, and poor infection prevention and control strategies are contributing to the emergence and dissemination of AMR. All healthcare providers play an important role in preventing the occurrence and spread of AMR. The organization of healthcare systems, availability of diagnostic testing and appropriate antibiotics, infection prevention and control practices, along with prescribing practices (such as over-the-counter availability of antibiotics) differs markedly between high-income countries and low and middle-income countries (LMICs). These differences may affect the implementation of antibiotic prescribing practices in these settings. The strategy to reduce the global burden of AMR includes, among other aspects, an in-depth modification of the use of existing and future antibiotics in all aspects of medical practice. The Global Alliance for Infections in Surgery has instituted an interdisciplinary working group including healthcare professionals from different countries with different backgrounds to assess the need for implementing education and increasing awareness about correct antibiotic prescribing practices across the surgical pathways. This article discusses aspects specific to LMICs, where pre-existing factors make surgeons’ compliance with best practices even more important.

Despite evidence supporting the effectiveness of best practices in infection prevention and management, many healthcare workers fail to implement them and evidence-based practices tend to be underused in routine practice. Prevention and management of infections across the surgical pathway should always focus on collaboration among all healthcare workers sharing knowledge of best practices. To clarify key issues in the prevention and management of infections across the surgical pathway, a multidisciplinary task force of experts convened in Ancona, Italy, on May 31, 2019, for a national meeting. This document represents the executive summary of the final statements approved by the expert panel.

Background: Postoperative acute pancreatitis (POAP) can be a possible cause of postoperative pancreatic fistula (POPF). The present study aimed to evaluate the role of clinically-relevant POAP (CR-POAP), defined according to different cut-offs of postoperative amylase (AMS) values and C-reactive protein (CRP), in the development of clinically relevant POPF (CR-POPF) after pancreaticoduodenectomy (PD). Methods: Data from 610 patients who underwent PD (2015- 2018) were analyzed. Patients were divided according to the upper limit (100 U/l) and 3-fold the upper limit (300 U/l) of serum POD1 AMS. Univariate and multivariable analysis of possible predictors of CR-POPF were performed. Results: Overall, 360 patients (59%) had POD1 serum AMS <= 100 U/l, 142 patients (23%) had POD1 serum AMS >100 U/l and <= 300 U/l, and 108 patients (18%) had POD1 serum AMS >300 U/l. Patients with POD1 serum AMS >300 had a higher frequency of soft pancreatic texture, complications, main pancreatic duct diameter <= 3 mm, and CR-POPF. POD1 serum AMS >100 U/l associated to POD2 CRP >= 180 mg/l (OR: 4.3, p < 0.001) was an independent predictor of CR-POPF. Conclusion: These results confirm that CR-POAP, defined as POD1 serum AMS >100 U/l and POD2 CRP >= 180 mg/l, is associated with an increased risk of CR-POPF.

INTRODUCTION:Inflammatory myofibroblastic tumor (IMT) is a rare proliferative disease of uncertain etiology, characterized by the proliferation of fusate or epithelioid myofibroblasts admixed with predominantly mononuclear inflammatory cells. IMT is generally considered a benign lesion, although in some cases this neoplasm has shown an aggressive behavior in terms of local recurrence and metastasis. We report the case of a patient with a ten-year history of ulcerative colitis affected by IMT of the transverse colon and by synchronous gastrointestinal stromal tumor (GIST) of stomach. PRESENTATION OF CASE:A 59-year-old woman with a ten-year history of ulcerative colitis has been admitted to our hospital with signs and symptoms of acute recurrence of ulcerative colitis: abdominal pain, diarrhea, hematochezia and rectal tenesmus. Colonoscopy showed a left colon with diffuse hyperemia, mucosal erosions and a 2-cm, irregularly shaped, polypoid lesion at the level of the transverse colon. Histopathological examination of the specimen obtained via biopsy of the polypoid lesion has revealed a mesenchymal neoplasm with uncertain characters of malignancy. Due to the severity of the inflammatory bowel disease resistant to immunosuppressive and steroid drug treatment, surgical indication was given. DISCUSSION:Although the relationship between IMT and Crohn's disease has been widely reported in literature, the relationship between IMT and ulcerative colitis has never been previously described. CONCLUSION:To the best of our knowledge, this is the first case of IMT associated with ulcerative colitis reported in literature and the synchronous association with a gastric GIST represents another primacy.

Background: The urachus is an embryonic remnant, which is obliterated in most of the adults. Residual of it persists in 32% of adults and neoplasms, which can arise from this structure, are extremely rare. These are usually diagnosed through incidental findings or for urinary symptoms. Their natural history is characterized by an early metastatization through the peritoneal cavity. Due to their rarity, there are no unanimous consensus for their management and therapy. Radical excision, associated or not with intraperitoneal hypertermic chemotherapy linked to cytoreductive surgery, was suggested over time.Case report: A black woman came to our attention for a gelatinous secretion from the umbilicus. After a MRIstudy, a parietal neoformation of the urachal remnants was diagnosed. This neoformation revealed a cutaneous fistulization and it was excised surgically. Its pathologic exam described the presence of a cystic mucinous urachal tumor. During the follow-up, a cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) was performed, due to the occurence of free intraperitoneal liquid and multiple nodules on the abdominal parenchimas, After the last surgery, the patient underwent radiological and serological follow up and, after 6 months, there are no evidence of pathological recurrence.Discussion and conclusion: In the diagnostic pathway, the MRI has a pivotal role for the study of the peritoneal cavity. Surgically, the complete excision is preferred. The role of the conventional chemotherapy is still under debate, however CRS in association with HIPEC, is certainly useful.

Background: This study aimed to develop and validate a preoperative prognostic model for death within one year post-surgery in patients with resectable pancreatic ductal adenocarcinoma (PDAC). Methods: A derivation cohort study of 296 patients who underwent surgical resection of PDAC was prospectively enrolled in an observational study. Preoperative predictors of one year mortality were used to develop a risk score which was then validated in an external cohort of 182 patients with resectable PDAC. Results: Seventy-eight out of 296 patients (26%) died within the first year. Preoperative independent predictors of one year mortality were: nutritional status (Geriatric Nutritional Risk Index, OR 2.23, 1.14-4.38; p = 0.02), American Society of Anaesthesiologists' score (OR 2.56, 1.1-5.98; p = 0.03), abdominal or back pain at presentation (OR 2.51, 1.05-5.9; p = 0.038) and non metastatic liver disease as comorbidity (OR 4.5, 1.05-19.3; p = 0.043). A score ranging from 0 to 7 points was developed. In the validation cohort, the model was able to predict early mortality (OR 7.1, 3.9-12.7; p < 0.0001), with a predictive ability of 53.5% (Nagelkerke R-2), an area under the receiver operating characteristic curve of 88.7% and an acceptable calibration (goodness-of-fit test, p = 0.403). Conclusions: Our new simple risk score proved reliable in forecasting one year mortality in patients with resectable PDAC. (C) 2017 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Background: An early recognition of clinically relevant pancreatic fistula (PF) after pancreaticoduodenectomy (PD) is essential.Methods: All consecutive patients who underwent PD in two institutions were included (2013-2015). In all patients amylase value in drains (AVD) was evaluated in postoperative day 1 (POD1). White-blood cell count (WBC), serum pancreatic amylase (SPA) and C-reactive protein (CRP) were routinely evaluated in POD1, POD2, and POD3. Receiver operator characteristic (ROC) curves were performed. Significant diagnostic cut-offs were tested in a multivariate model.Results: Overall, 463 patients underwent PD. Postoperative morbidity and mortality were 58% and 4%, respectively. Sixty-four patients (14%) had a clinically relevant PF (grade B or C). ROC curve analyses revealed that AVD on POD1 had the greatest area under the curve value (0.881, P < 0.0001) followed by CRP on POD3 (0.796, P < 0.0001). Multivariable analysis identified male gender (OR 2.29 95% CI: 1.12-4.70, P = 0.023), AVD on POD1> 500 U/l (OR 21.72, 95% CI: 7.41-63.67, P < 0.0001), CRP on POD2 > 150 mg/l (OR 3.480, 95% CI: 1.21-9.99, P = 0.021), and CRP on POD3 > 185 mg/l (OR 6.738, 95% CI: 1.91-23.78, P = 0.003) as independent predictors of clinically relevant PF.Conclusion: The combination of CRP and AVD was effective in the early prediction of clinically relevant POPF after PD.

This declaration, signed by an interdisciplinary task force of 234 experts from 83 different countries with different backgrounds, highlights the threat posed by antimicrobial resistance and the need for appropriate use of antibiotic agents and antifungal agents in hospitals worldwide especially focusing on surgical infections. As such, it is our intent to raise awareness among healthcare workers and improve antimicrobial prescribing. To facilitate its dissemination, the declaration was translated in different languages.

Background: Recent evidence has shown that enhanced recovery after surgery (ERAS) protocols decrease hospital stay following pancreaticoduodenectomy (PD). The aims of this study were to assess the feasibility and to evaluate the effect of introducing ERAS principles after PD in elderly patients.Methods: Patients >= 75 years were defined as elderly. Comparison of postoperative outcome was performed between 22 elderly patients who underwent ERAS (elderly ERAS + patients) and a historical cohort of 66 elderly patients who underwent standard protocols (elderly ERAS-patients).Results: The lowest adherence with ERAS among elderly patients was observed for starting a solid food diet within POD 4 (n = 7) and early drains removal (n = 2). The highest adherence was observed for post-operative glycemic control (n = 21), epidural analgesia (n = 21), mobilization (n = 20) and nasogastric removal in POD 0 (n = 20). Post-operative outcomes did not differ between elderly ERAS+ and elderly ERAS- patients. In patients with an uneventful postoperative course, the median intention to discharge was earlier in elderly ERAS + patients as compared to the elderly ERAS- patients (4 days versus 8 days, P < 0.001).Conclusion: An ERAS protocol following PD seems to be feasible and safe among elderly although it is not associated with improved postoperative outcomes.

Background: Postoperative complications may have an adverse effect not only on short-term but also long-term outcome among patients having surgery for cancer. Aim of this study was to assess a possible association between postoperative complications and long-term survival after resection for pancreatic ductal adenocarcinoma (PDA). Methods: Patients who had surgery with curative intent for PDA (2009 to 2013) were included. Postoperative complications were classified into minor (grade 1–2) and major (grade 3–4). The impact of postoperative complications, patient and tumor characteristic, disease stage and treatment on long-term survival was analyzed using multivariable Cox regression models. Results: A total of 209 patients underwent curative surgery for PDA. Of these, 2 patients died after surgery and they were excluded from the study. Overall, 207 patients were included. The median age was 65 years (interquartile range 60–71) and there were 95 women (46%). A minor or major postoperative complication developed in 65 (31%) and 48 (23%) patients, respectively. The median disease-specific survival (DSS) and disease free survival (DFS) were 36 months and 19 months, respectively. Multivariable analysis revealed that major postoperative complications independently predicted shorter DSS [hazard ratio (HR) 1.580, 95% confidence interval (CI) 1-020-2.446; P = 0.040] and DFS (HR 1.517, 95% CI 1.034–2.224; P = 0.033). Other independent predictors of DSS and DFS included tumor grading, lymph node ratio (LNR), and portal vein resection. Conclusion: Postoperative major complications were independently associated with decreased long-term survival after surgery for PDA with curative intent. The prevention and management of postoperative complications might have a significant oncological impact.

Background: Prevalence and incidence of hepatic haemangioma are estimated from autopsy series only. Although benign and generally asymptomatic, hepatic haemangioma can cause serious complications.Aims: The aim of the study was to assess the prevalence of hepatic haemangioma and to attempt to quantify the risk of major complications such as spontaneous rupture.Methods: We retrospectively analyzed the radiology database of a Regional University Hospital over a 7-year period: the radiological records of 83,181 patients who had an abdominal computed tomography or magnetic resonance scan were reviewed. Diagnoses made at imaging were reviewed and related to clinical course.Results: Hepatic haemangioma was diagnosed in 2071 patients (2.5% prevalence). In 226 patients (10.9%), haemangioma had diameter of 4 cm or more (giant haemangioma). The risk of bleeding was assessed on patients without concomitant malignancies. Spontaneous bleeding occurred in 5/1067 patients (0.47%). All 5 patients had giant haemangioma: 4 had exophytic lesions and presented with haemoperitoneum; 1 with centrally located tumour experienced intrahepatic bleeding.Conclusion: Giant haemangiomas have a low but relevant risk of rupture (3.2% in this series), particularly when peripherally located and exophytic. Surgery might be considered in these cases. (C) 2015 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

PURPOSE The discovery of Imatinib mesylate (Gleevec®) has revolutionized the treatment of GIST, increasing diseasefree survival (DFS) after complete surgical resection of a primary localized GIST and extending overall survival in metastatic disease. The definition of an accurate prognostic system is critical for the therapeutic decision making process. In literature, there are three main prognostic criteria F/NIH consensus, AFIP standards and modified NIH standards. In recent years were added various risk identification methods applying mathematical calculation model, including MSKCC risk nomogram, Rossi nomogram and Joensuu high Hotline Dengjun. Despite all these attempts, it seems that the recurrence risk probability still cannot be predicted accurately. The aim of our study was to assess and compare the real ability of these prognostic instruments in our single-centre clinical experience, and to define if the use of the MSKCC nomogram can bring benefits in the therapeutic decision. METHODS All data regarding 37 GIST, who underwent surgical resection from 1996 to 2011 in our institution were retrospectively reviewed. We selected only primary GIST without metastatic disease who underwent a radical resection (R0) but no other therapy. The literature data concerning GISTs prognostication criteria were reviewed. All patients were classified according to the three prognostic criteria (NIH, AFIP and Nomogram MSKCC) and the three instruments were compared with the Kaplan-Meier method. Then we compared the three criteria for their c-index value and we assessed the performance of the nomogram with the calibration test. RESULTS We observed 9 recurrences (24%) with an average time to relapse of 43 months; the median follow-up was 65 months. In the study selected sample occurred 5 relapses. The probability of relapsing after radical surgery was 7.9% (95% CI 0 - 17.3) at 2 years and 13.3% at 5 years (95% CI 0 - 26.4). The C-Index of the three risk assessment tools was 0.93 (95% CI 0.83-1) for the Nomogram at 5 years, 0.86 (95% CI 0.76-0.95) for the NIH risk criteria and 0.88 (95% CI 0.74-1) for the AFIP risk criteria. The calibration analysis of the nomogram showed an overestimating trend both at 2 and 5 years. CONCLUSION MSKCC nomogram seems to perform better than NIH, NIH modified and AFIP in our sample and can be used in clinical practice to predict the risk of recurrence, being especially helpful for the therapeutic decision making since it is at the same time simple to use and accurate. As showed from calibration, MSKCC doesn't seem to neglect relapses, even though it is not impeccable in predicting the RFS. Among the 2 older criteria AFIP was more precise than NIH, but considering size in not linear way represented a limit in comparison with the MSKCC Nomogram. All the three risk assessement tools criteria con sidered are capable to predict recurrence in high-risk GISTs while they performed worse in those with lower risk. MSKCC nomogram main limit remains the not linear consideration of mitotic count.

Background: Surgical site infection (SSI) is among the most frequent hospital-acquired infections occurring in surgical patients and leads to increased morbidity, mortality, and costs. We aimed to identify risk factors for SSI in patients undergoing surgical procedures, with a particular attention to the use of drains.Methods: This study includes all patients undergoing abdominal surgical procedures in 2 surgical wards in a teaching hospital in central Italy. Collected data included patient's demographic and clinical characteristics, procedure characteristics, administration of perioperative antibiotic prophylaxis, and microorganism isolated. The outcome of interest was SSI.Findings: A total of 872 abdominal surgery procedures were surveyed during the study period. Drains were placed in 37.0% of cases. SSI rate was 6.4% globally and 13.6% among the patients with drains, versus 2.4% in those without a drain (P < .001). In 72.1% of cases antibiotic prophylaxis was administered. The logistic regression analysis (P < .001) shown insertion of a drain (odds ratio [OR], 5.14; 95% confidence interval [CI], 2.63-10.08), prolonged surgery (OR, 1.98; 95% CI, 1.09-3.59), and American Society of Anesthesiologists score equal to 3 (OR, 6.13; 95% CI, 2.33-16.11) as independent risk factors for SSI, whereas antibiotic prophylaxis was protective (OR, 0.53; 95% CI, 0.29-0.99).Conclusion: This study revealed surgical drains as a risk factor for SSI, pointing out the need of a clearer understanding of drain role in the dynamics of SSI occurrence, with the purpose of decreasing infection risk through targeted preventive interventions. (C) 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

AIM:We want to show a new organisational model of General Surgery training, in act in Università Politecnica delle Marche, which sees its strength in the territorial formative network.MATERIAL OF STUDY:In our Athenaeum, this organization is not a recent realization, but the firsts to have benefited completely of this system are the four residents who have completed the General Surgery formation in March 2014, for this reason we report their experience.RESULTS:The four residents benefited of the two years in the peripheral structures, two also performed a period in a foreign country, two chose to spend other 6 months in the peripheral structure to prepare the thesis of specialization; surgical activity has been, for each resident, of 400 interventions on average as first operator (237-476) distributed in great surgery 44 (13-80), middle 172 (129-268) and small 209 (70-378).DISCUSSION:The Formative NETWORK becomes an essential strength at the service of the academic world, the network foresees a continuous update, it can be easily standardized for every resident and it doesn't raise barriers to the foreign countries experiences.CONCLUSIONS:With the purpose to conform the model of specialistic formation in General Surgery, we propose a new tailored italian organizational model, tested the lasts 6 years, which seems to give good results and conform to the european standard of surgical training.KEY WORDS:Formative network, General Surgery, Resident, Training.

Patient: Male, 67Final Diagnosis: Metastatic gastric carcinomaSymptoms: Painful swelling of soft tissueMedication: Folinic acid center dot fluouracil center dot irinotecanClinical Procedure: Radiological-pathological work-upSpecialty: OncologyObjective: Rare diseaseBackground: Gastric carcinoma is one of the most common malignancies in the world. Skeletal muscle metastases from gastric carcinoma are rare.Case Report: We report a case of a 67-year-old man patient with skeletal muscle metastasis developing from gastric carcinoma. He had a painful swelling of the left thigh. A chest computed tomography (CT) scan with enhancement showed pulmonary thromboembolism. Despite heparin therapy, edema and pain of the lower limbs increased bilaterally, so the patient underwent pelvic magnetic resonance imaging (MRI), which documented an altered signal intensity in the upper third of his thighs bilaterally. Furthermore, the examination of the ultrasound (US)guided biopsy specimen of the left gluteal muscle showed signet ring cell adenocarcinoma metastasis. An upper gastrointestinal tract endoscopy confirmed a gastric ulceration, with a biopsy positive for signet ring cell adenocarcinoma. Because of the advanced stage of disease, the patient underwent only supportive care and died 74 days after admission.Conclusions: Skeletal muscle metastasis may be the initial presentation of gastric carcinoma and diagnosis could be difficult. Biopsy is mandatory for diagnosis.