Enhanced recovery pathways in colorectal surgery: a consensus paper by the Associazione Chirurghi Ospedalieri Italiani (ACOI) and the PeriOperative Italian Society (POIS)

Enhanced Recovery After Surgery (ERAS) pathway is a multi-disciplinary, patient-centered protocol relying on the implementation of the best evidence-based perioperative practice. In the field of colorectal surgery, the application of ERAS programs is associated with up to 50% reduction of morbidity rates and up to 2.5 days reduction of postoperative hospital stay. However, widespread adoption of ERAS pathways is still yet to come, mainly because of the lack of proper information and communication. Purpose of this paper is to support the diffusion of ERAS pathways through a critical review of the existing evidence by members of the two national societies dealing with ERAS pathways in Italy, the PeriOperative Italian Society (POIS) and the Associazione Italiana Chirurghi Ospedalieri (ACOI), showing the results of a consensus development conference held at Matera, Italy, during the national ACOI Congress on June 10, 2019.

Radiation dose intensification in pre-operative chemo-radiotherapy for locally advanced rectal cancer

BACKGROUND

To assess the role of radiation dose intensification with simultaneous integrated boost guided by 18-FDG-PET/CT in pre-operative chemo-radiotherapy (ChT-RT) for locally advanced rectal cancer.

METHODS

A prospective study was approved by the Internal Review Board. Inclusion criteria were: age >18 years old, World Health Organization performance status of 0-1, locally advanced histologically proven adenocarcinoma of the rectum within 10 cm of the anal verge, signed specific informed consent. High-dose volumes were defined including the hyper-metabolic areas of 18-FDG-PET/CT of primary tumor and the corresponding mesorectum and/or pelvic nodes with at least a standardized uptake values (SUV) of 5. A dose of 60 Gy/30 fractions was delivered. A total dose of 54 Gy/30 fractions was delivered to prophylactic areas. Capecitabine was administered concomitantly with RT for a dose of 825 mg/mq twice daily for 5 days/every week.

RESULTS

Between September 2011 and July 2015 fortypatients were recruited. At the time of the analysis, median follow up was 20 months (range 5-51). The median interval from the end of ChT-RT to surgery was 9 weeks (range 8-12). Thirty-seven patients (92.5 %) were submitted to sphincter preservation. Tumor Regression Grade (Mandard scale) was recorded as follows: grade 1 in 7 (17.5 %), grade 2 in 17 (42.5 %), grade 3 in 15 (37.5 %) and grade 4 in 1 (2.5 %). Post-surgical circumferential resection margin was negative in all patients. A tumor downstaging was reported in 62.5 % (95 % CI: 0.78-0.47). A nodes downstaging was registered in 85 % (95 % CI: 0.55-0.25). 18-FDG-PET/CT was not able to predict pCR. No correlation was found between pre-treatment SUV-max values and pCR. A metabolic tumor volume >127 cc was related to ypT ≥2 (p 0.01). Patients with TRG >2 had higher tumor lesion glycolysis values (p 0.05).

CONCLUSION

Preliminary results did not confirm some advantages in terms of primary tumor downstaging/downsizing compared to conventional schedules reported in historical series. The role of 18-FDG-PET/CT in neoadjuvant rectal cancer management needs to be confirmed in further investigations. Long terms results are necessary.

Evaluation of an enhanced recovery protocol after pancreaticoduodenectomy in elderly patients

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 naso-gastric 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.

A global approach to psoriatic patients through PASI score and Skindex-29

AIM

Psoriasis is a chronic immune-mediated inflammatory skin disorder affecting approximately 2% of the population worldwide. Because of its visible manifestations and symptoms, psoriasis has profound effects on quality of life (QoL). Our objective is to determine the clinical severity of psoriasis and its impact on QoL in patients treated with phototherapy, traditional systemic therapy and biological therapy.

METHODS

Patients with plaque-type psoriasis and psoriatic arthritis were recruited at a PsoCare centre and followed up for 6 months. Psoriasis severity was assessed based on the Psoriasis Area and Severity Index (PASI) score and QoL using the SKINDEX-29 questionnaire.

RESULTS

PASI score improved significantly in all patients after 6 months of therapy. The greatest improvement was observed in patients receiving biological treatments. PASI-75 was obtained by 46.9% of patients on phototherapy and 43.1% on biological therapies. Skindex-29 results did not significantly differ among the three treatment groups.

CONCLUSION

Effective management of patients with psoriasis depends on the appropriate assessment of both the physical and psychosocial impact of the disease.

Evaluation of colonic involvement in endometriosis: double-contrast barium enema vs. magnetic resonance imaging

BACKGROUND

The purpose of the study was to compare the accuracy of double-contrast barium enema (DCBE) and magnetic resonance imaging (MRI) in the diagnosis of intestinal endometriosis using the histological examination on resected specimen as comparative standard.

METHODS

Eighty-three consecutive patients with suspected intestinal endometriosis, resected between 2005 and 2007, were prospectively evaluated. All of the women underwent preoperative DCBE and MRI on the same day. We evaluated number, site (rectum, sigmoid, cecum), and size of the lesions. The imaging findings were correlated with those resulting at pathology.

RESULTS

Among the 65 women who underwent surgery, 50/65 (76.9%) were found to have bowel endometriosis, with 9/50 (18%) patients presenting two lesions; DCBE allowed to detect 50/59 (84.7%) lesions. MRI allowed to detect 42/59 (71.1%) lesions. DCBE showed sensibility, specificity, PPV, NPV, and accuracy of respectively 84.7, 93.7, 98.0, 62.5, and 86.6%, MRI of 71.1, 83.3, 93.3, 46.8, and 74.6%.

CONCLUSION

DCBE is more accurate than unenhanced MRI in the diagnosis of bowel endometriosis, and should be preferred in the preoperative management of this disease, since it usually enables a proper surgical planning.

Laparoscopic treatment of bowel endometriosis in infertile women

BACKGROUND

The purpose of the study was to determine the influence of bowel endometriosis on fertility, and to study whether its removal improves fecundity in women with endometriosis-associated infertility.

METHODS

Three groups of infertile patients were included in the study. Group A (60 women) consisted of patients who underwent surgery for endometriosis with colorectal segmental resection. In group B, 40 patients with evidence of bowel endometriosis underwent endometriosis removal without bowel resection. Group C consisted of 55 women who underwent surgery for moderate or severe endometriosis with at least one endometrioma and deep infiltrating endometriosis but without bowel involvement. The women were clinically evaluated before laparoscopy and then at 1 month, at 6 months and at each year up to 4 years after surgery. Main outcome measures were surgical complications as well as post-operative pregnancy rate, time to conception and monthly fecundity rate.

RESULTS

The monthly fecundity rates (MFR) in groups A, B and C were 2.3, 0.84 and 3.95%, respectively. The difference in the MFR between groups was significant (P < 0.05).

CONCLUSIONS

The presence of bowel infiltration by endometriosis seems to negatively influence the reproductive outcome in women with endometriosis-associated infertility. The complete removal of endometriosis with bowel segmental resection seems to offer better results in terms of post-operative fertility.

Laparoscopic nerve-sparing complete excision of deep endometriosis: is it feasible?

BACKGROUND

Little is known about the morbidity associated with laparoscopic complete excision of endometriosis in terms of urinary, digestive and sexual function.

METHODS

We performed a prospective non-randomized study in 45 patients with laparoscopic complete excision of all detectable foci of endometriosis with segmental bowel resection using a non nerve-sparing technique (control group-group A n=20) and a nerve-sparing technique (case group-group B n=25). At initial gynaecological evaluation, and at follow-up details on dysmenorrhoea, pelvic pain, dyspareunia and dyschezia were evaluated using an interview-based questionnaire (10-point analogue rating scale: 0=absent, 10=unbearable).

RESULTS

The mean (+/-SD) follow-up period was 15.3+/-10 months (range, 8.8-23 months) for group A and 3.5+/-2.1 months (range, 0.3-5.2 months) for group B. In the immediate postoperative course, in group A three women required blood transfusion vs seven women in group B (P=0.003). The median time to resume the voiding function was significantly shorter in group B (12.5 vs 3.0 days; P<0.01). At the time of follow-up a higher proportion of patients in group B were 'very satisfied' than those in group A (87.7% vs 59.0%, P=0.013).

CONCLUSIONS

Laparoscopic nerve-sparing complete excision of endometriosis seems to be feasible and offers good results in terms of bladder morbidity reduction with apparently higher satisfaction than classical technique. Larger series with longer follow-up are needed to confirm our results.

Subclinical Mastitis and Antimicrobial Susceptibility of Staphylococcus caprae and Staphylococcus epidermidis Isolated from Two Italian Goat Herds

A total of 156 goats from 2 commercial dairy goat farms were monitored for intramammary infections during an entire lactation. Most of the infections (80.7%) observed were due to coagulase-negative staphylococci (CNS) species. In herd 1, nearly all of the infections (96%) were due to CNS species, with Staphylococcus caprae (SCAP) being the most common specific pathogen observed, accounting for about 43% of the infections. In herd 2, the proportion of the infections due to CNS was 67% and Staphylococcus epidermidis (SEPI) was the most common pathogen (48% of infections) and SCAP was not present. Linear somatic cell scores (SCS) were greater in milk from infected udder halves, with an average difference of 0.78 SCS. The SCS for infected udder halves was greater than noninfected for all CNS species, although differences among species were observed. The ranking across CNS species was SCAP > other CNS > SEPI > no infection. However, infections by SEPI tended to be more persistent. Increased SCS was associated with a statistically significant decrease in milk yield, but no effect was observed for intramammary infections (IMI). Ninety-seven isolates of CNS (53 SCAP and 44 SEPI) were investigated for in vitro susceptibility to several antimicrobial agents. Benzylpenicillin was the most effective antimicrobial agent against SCAP and SEPI. A concentration of 0.05 microg/mL was sufficient to inhibit growth of 90% of SCAP colonies, and 0.10 microg/mL yielded a similar effectiveness for SEPI. Amoxicillin and the combination of amoxicillin and clavulanic acid were only slightly less effective. Tetracycline (62.5 microg/mL) and tilmicosin (500 microg/mL) were the least effective treatments for SEPI and SCAP, respectively.

Risk factors for intramammary infections and relationship with somatic-cell counts in Italian dairy goats

Routine examination of milk was performed on five herds of lactating goats in northern Italy as part of a milk quality-monitoring program in the year 2000. As part of the study, aseptic samples of foremilk were collected monthly from both half udders during the entire lactation for 305 goats, resulting in a total of 4571 samples. The samples were tested with cytological and bacteriological analyses to evaluate the relationship between mammary infections and somatic-cell count (SCC; Fossomatic (TM) method). Prevalence of intramammary infection (IMI) was 40.2% (n = 1837) of all udder-half samples examined. The most-prevalent mastitis agents were coagulase-negative Staphylococci (CNS), 80% (n = 1474 udder-half samples); within this group, Staphylococcus epidermidis was the most-prevalent species (38%). Other prevalence were Staphylococcus aureus 6% (n = 112 udder-half samples) and environmental pathogens 14% of infected udder-half samples (n = 251) with a diverse mixture of species, none of which had a frequency of > 4%. Enterococcus faecalis was the most-frequently isolated among this group. Neither Salmonella spp. nor Listeria monocytogenes were detected. The risk (sample level) of infection differed across herds, parities, and stage of lactation according to results from logistic multiple regression. Infection was more common among goats in third and fourth parities and during the later stages of lactation. Of the 2734 samples from uninfected udder halves, the mean log2 SCC was 3.9 cell/ml; of the 1837 bacteriological positive samples, the mean log2 SCC was 5.6 cell/ml. According to results from a linear mixed model, concentrations of somatic cells tended to increase with increasing age and days in milk and with the presence of bacteria. Infection with S. aureus was associated with the highest SCS.

Distribution pattern of bovine viral diarrhoea virus strains in intensive cattle herds in Italy

The genetic variation of bovine viral diarrhoea virus (BVDV) was studied by comparative nucleotide sequence analysis of 26 Italian field strains collected during the period 1995-2000 in 18 cattle herds. A fragment within the 5'-untranslated region (UTR) was sequenced directly from gel-purified products obtained by reverse transcription polymerase chain reaction. BVDV-1b (n=14), -1c (n=1), -1d (n=1) and BVDV-2 (n=2) strains have been isolated. Most herds were infected by BVDV-1b. Pairwise similarity and cluster analysis of the remaining BVDV-1 isolates (n=8) did not provide a clear-cut assignation to defined BVDV-1 groups. This is the first time that a BVDV-2 isolation was reported in Italy. Among BVDV-2 reference strains, Italian BVDV-2 isolates showed the highest sequence similarity with the CD87 strain. Both BVDV-2 strains were isolated in two healthy animals from different herds. The 5'-UTR sequence of one of the two BVDV-2 strains was identical to a German BVDV field strain. Complete nucleotide homology was found only among BVDV strains isolated from the same herd, showing a herd-specific clustering. Moreover, 99.6% homology was observed between strains from herds linked by livestock trade. Despite the small number of BVDV isolates analysed, it revealed a high level of genetic diversity among Italian field BVDV strains.

Recovery of Staphylococcus aureus from centrifuged quarter milk samples

The identification of cows that are positive for mastitis caused by Staphylococcus aureus is difficult under field conditions. The frequency of isolation of S. aureus from quarter milk samples was compared with the frequency of recovery of S. aureus from sediment after centrifugation of those same samples. Overall, 776 quarter milk samples from 194 cows were studied. Cultures that were positive for S. aureus were obtained from 82 samples; 153 sediments from quarter milk samples were also positive for S. aureus. The results of this investigation showed that cultures of the sediment of quarter milk samples increased the number of positive outcomes up to 145.5%, depending on the herd. Using a different group of samples, including samples taken 1 to 5 d or 7 to 10 d after calving and samples taken after intramammary therapy, a 94% increase in cultures that were positive for S. aureus after centrifugation was found compared with cultures of the same quarter milk samples that were not centrifuged. Sedimented cultures may be useful in S. aureus control programs that require the segregation, selective treatment, or culling of cows that are positive for S. aureus.

Field study on the relationship between teat thickness changes and intramammary infections

The aim of this study was to describe the results of teat thickness measurement applied routinely in three commercial dairy herds and to evaluate the influence of machine-induced teat thickness changes on intramammary infection and the frequency of new infection. A total of 1018 fore milk samples and the same number of teat apex measurements have been evaluated. Overall, relative teat thickness changes were normally distributed (mean -0.16%, SD 10.15%), while a specific pattern could be observed within herds. Increases in teat thickness of > 5% were significantly associated with infection and new infection (odds ratio > 1), but the association was not significant when teat thickness decreased by more than 5%. When results were classified according to aetiology, analysis showed that coagulase-negative staphylococcal infections were significantly associated with both increases and decreases in teat thickness numerically greater than 5%.

Phagocytic activity of bovine polymorphonuclear neutrophil leucocytes

Two different investigations were conducted on the chemiluminescent activity of bovine milk polymorphonuclear neutrophil leucocytes (PMN) activated by different stimuli: zymosan, derived from the wall of Saccharomyces cerevisiae (Experiment A), and Streptococcus uberis and Escherichia coli (Experiment B). In Experiment A, a quarter with a phagocytic activity of PMN < 20 mV/1000 PMN following stimulation with zymosan was found to be 23 times more likely to be a clinical mastitis case than a quarter with phagocytic activity above this threshold value. In Experiment B, calculation of the odds ratio showed similar results following stimulation with Str. uberis or Esch. coli. These results provide evidence that immunocompromisation of mammary gland defences could predispose to clinical mastitis. They also support the need to challenge phagocytic cells with appropriate stimuli, and the Esch. coli test seems to be the most sensitive.

Machine-induced teat tissue reactions and infection risk in a dairy herd free from contagious mastitis pathogens

Machine-induced changes in teat thickness were measured in a randomly selected group of 22 cows from a commercial dairy herd consisting of 110 cows during an experiment lasting 1 year. Half the cows used were free from mastitis whereas the remainder had at least one quarter infected by environmental pathogens. Teats were classified according to a threshold change in teat end thickness of 5%. The relationships between quarter infection or teat duct colonization and teat end thickness changes induced by machine milking were investigated. Teats with greater than 5% change in thickness had significantly increased teat duct colonization and a slight, non-significant, increase in quarter infection. We conclude that machine-induced changes in teat end thickness are predisposing factors for teat duct colonization by environmental pathogens. This may provide an increased new infection risk, especially when hygiene is poor.

Experimental results of the use of flavofosfolipol in dairy cattle

In a field trial carried out on a farm with about 100 dairy cows, half of the animals were treated orally with 45 mg flavofosfolipol per animal daily for 370 days, while the other half were untreated controls. The administration of the flavofosfolipol did not produce any residues in the milk. Body functions and fertility were not affected. Milk production was increased, although not with statistical significance. The qualitative characteristics of the milk and its cheese-making properties were normal. The casein content was increased by 6.58% over that of the controls, and thus was statistically significant. There was a statistically significant decrease in the mean cell content of the milk. The high negative correlation between the casein level and the cell content of the milk suggests that an improvement in the function of the mammary parenchyma could be responsible for the higher casein content. This improvement in function could also be due to a favourable effect of the antibiotic, still to be clarified, on the ruminal microflora. In economic terms the use of flavofosfolipol in dairy cattle seems to be of considerable interest.

Machine milking: experimental observations on the life of teat-cup liners

The useful life of neoprene teat-cup liners used in milking machines was determined by physico-mechanical, optical and microbiological studies. The various tests showed that after more than 1,000 hrs' use, that is the milking time plus disinfection time, there were physico-mechanical and biological changes that could have an adverse effect on the health of the udder as a result of a loss of elasticity and a dissemination of mastitis-producing microorganisms (S. agalactiae, S. aureus) which settle in cracks in the surface of the rubber.