Impact of Positive End-Expiratory Pressure and FiO2 on Lung Mechanics and Intrapulmonary Shunt in Mechanically Ventilated Patients with ARDS Due to COVID-19 Pneumonia

Purpose: This study aimed to investigate the effects of inspired oxygen fraction (FiO2) and positive end-expiratory pressure (PEEP) on gas exchange in mechanically ventilated patients with COVID-19. Methods: Two FiO2 (100%, 40%) were tested at 3 decreasing levels of PEEP (15, 10, and 5 cmH2O). At each FiO2 and PEEP, gas exchange, respiratory mechanics, hemodynamics, and the distribution of ventilation and perfusion were assessed with electrical impedance tomography. The impact of FiO2 on the intrapulmonary shunt (delta shunt) was analyzed as the difference between the calculated shunt at FiO2 100% (shunt) and venous admixture at FiO2 40% (venous admixture). Results: Fourteen patients were studied. Decreasing PEEP from 15 to 10 cmH2O did not change shunt (24 [21-28] vs 27 [24-29]%) or venous admixture (18 [15-26] vs 23 [18-34]%) while partial pressure of arterial oxygen (FiO2 100%) was higher at PEEP 15 (262 [198-338] vs 256 [147-315] mmHg; P < .05). Instead when PEEP was decreased from 10 to 5 cmH2O, shunt increased to 36 [30-39]% (P < .05) and venous admixture increased to 33 [30-43]% (P < .05) and partial pressure of arterial oxygen (100%) decreased to 109 [76-177] mmHg (P < .05). At PEEP 15, administration of 100% FiO2 resulted in a shunt greater than venous admixture at 40% FiO2, ((24 [21-28] vs 18 [15-26]%, P = .005), delta shunt 5.5% (2.3-8.8)). Compared to PEEP 10, PEEP of 5 and 15 cmH2O resulted in decreased global and pixel-level compliance. Cardiac output at FiO2 100% resulted higher at PEEP 5 (5.4 [4.4-6.5]) compared to PEEP 10 (4.8 [4.1-5.5], P < .05) and PEEP 15 cmH2O (4.7 [4.5-5.4], P < .05). Conclusion: In this study, PEEP of 15 cmH2O, despite resulting in the highest oxygenation, was associated with overdistension. PEEP of 5 cmH2O was associated with increased shunt and alveolar collapse. Administration of 100% FiO2 was associated with an increase in intrapulmonary shunt in the setting of high PEEP. Trial registration: NCT05132933.

Treatment with inhaled Argon: a systematic review of pre-clinical and clinical studies with meta-analysis on neuroprotective effect

BACKGROUND

Argon (Ar) has been proposed as a potential therapeutic agent in multiple clinical conditions, specifically in organ protection. However, conflicting data on pre-clinical models, together with a great variability in Ar administration protocols and outcome assessments, have been reported. The aim of this study was to review evidence on treatment with Ar, with an extensive investigation on its neuroprotective effect, and to summarise all tested administration protocols.

METHODS

Using the PubMed database, all existing pre-clinical and clinical studies on the treatment with Ar were systematically reviewed (registration: https://doi.org/10.17605/OSF.IO/7983D). Study titles and abstracts were screened, extracting data from relevant studies post full-text review. Exclusion criteria included absence of full text and non-English language. Furthermore, meta-analysis was also performed to assess Ar potential as neuroprotectant agent in different clinical conditions: cardiac arrest, traumatic brain injury, ischemic stroke, perinatal hypoxic-ischemic encephalopathy, subarachnoid haemorrhage. Standardised mean differences for neurological, cognitive and locomotor, histological, and physiological measures were evaluated, through appropriate tests, clinical, and laboratory variables. In vivo studies were evaluated for risk of bias using the Systematic Review Center for Laboratory Animal Experimentation tool, while in vitro studies underwent assessment with a tool developed by the Office of Health Assessment and Translation.

FINDINGS

The systematic review detected 60 experimental studies (16 in vitro, 7 ex vivo, 31 in vivo, 6 with both in vitro and in vivo) investigating the role of Ar. Only one clinical study was found. Data from six in vitro and nineteen in vivo studies were included in the meta-analyses. In pre-clinical models, Ar administration resulted in improved neurological, cognitive and locomotor, and histological outcomes without any change in physiological parameters (i.e., absence of adverse events).

INTERPRETATION

This systematic review and meta-analysis based on experimental studies supports the neuroprotective effect of Ar, thus providing a rationale for potential translation of Ar treatment in humans. Despite adherence to established guidelines and methodologies, limitations in data availability prevented further analyses to investigate potential sources of heterogeneity due to study design.

FUNDING

This study was funded in part by Italian Ministry of Health-Current researchIRCCS and by Ministero della Salute Italiano, Ricerca Finalizzata, project no. RF 2019-12371416.

Mucinous appendiceal neoplasms: Report of a case and brief literature review

INTRODUCTION

Appendiceal tumors are rare neoplasms detected in about 2 % of appendicectomies. The clinical presentation is often unspecific, varying from unspecific abdominal pain or presenting as an acute appendicitis or being asymptomatic.

CASE PRESENTATION

We present a case of a patient presenting as an acute appendicitis with a mucocele, and then classified as HAMN. The patient was treated with initial laparoscopic approach and then conversion in laparotomy with appendectomy. Histology demonstrated a high grade appendiceal mucinous neoplasm limited to submucosa (pT3), with concomitant acute phlegmonous appendicitis. The patient was subsequently sent to a referral center where a right hemicolectomy with HIPEC was performed.

DISCUSSION

HAMN is a rare entity, only recently classified as a new kind of appendiceal mucinous neoplasm. Due to the supposed higher aggressivity, HAMN must be treated as an appendiceal adenocarcinoma. The treatment of this rare entity is not yet well standardized, because of the rarity of this disease.

CONCLUSION

HAMN is a very rare tumor. In the emergency setting, it is mandatory to avoid rupture of the appendix, to minimize the risk of developing pseudomyxoma peritonei. Pathology is essential for further decisions in these patients and plays a very important role in treatment and prognosis.

Enhanced extracorporeal carbon dioxide removal by acidification and metabolic control

BACKGROUND

Extracorporeal carbon dioxide removal (ECCO2R) promotes protective ventilation in patients with acute respiratory failure, but devices with high CO2 extraction capacity are required for clinically relevant impact. This study evaluates three novel low-flow techniques based on dialysate acidification, also combined with renal replacement therapy, and metabolic control.

METHODS

Eight swine were connected to a low-flow (350 mL/min) extracorporeal circuit including a dialyzer with a closed-loop dialysate circuit, and two membrane lungs on blood (MLb) and dialysate (MLd), respectively. The following 2-hour steps were performed: 1) MLb-start (MLb ventilated); 2) MLbd-start (MLb and MLd ventilated); 3) HLac (lactic acid infusion before MLd); 4) HCl-NaLac (hydrochloric acid infusion before MLd combined with renal replacement therapy and reinfusion of sodium lactate); 5) HCl-βHB-NaLac (hydrochloric acid infusion before MLd combined with renal replacement therapy and reinfusion of sodium lactate and sodium 3-hydroxybutyrate). Caloric and fluid inputs, temperature, blood glucose and arterial carbon dioxide pressure were kept constant.

RESULTS

The total MLs CO2 removal in HLac (130±25 mL/min), HCl-NaLac (130±21 mL/min) and HCl-βHB-NaLac (124±18 mL/min) were higher compared with MLbd-start (81±15 mL/min, P<0.05) and MLb-start (55±7 mL/min, P<0.05). Minute ventilation in HLac (4.3±0.9 L/min), HCl-NaLac (3.6±0.8 L/min) and HCl-βHB-NaLac (3.6±0.8 L/min) were lower compared to MLb-start (6.2±1.1 L/min, P<0.05) and MLbd-start (5.8±2.1 L/min, P<0.05). Arterial pH was 7.40±0.03 at MLb-start and decreased only during HCl-βHB-NaLac (7.35±0.03, P<0.05). No relevant changes in electrolyte concentrations, hemodynamics and significant adverse events were detected.

CONCLUSIONS

The three techniques achieved a significant extracorporeal CO2 removal allowing a relevant reduction in minute ventilation with a sufficient safety profile.

Association of COVID-19 Vaccinations With Intensive Care Unit Admissions and Outcome of Critically Ill Patients With COVID-19 Pneumonia in Lombardy, Italy

Importance

Data on the association of COVID-19 vaccination with intensive care unit (ICU) admission and outcomes of patients with SARS-CoV-2-related pneumonia are scarce.

Objective

To evaluate whether COVID-19 vaccination is associated with preventing ICU admission for COVID-19 pneumonia and to compare baseline characteristics and outcomes of vaccinated and unvaccinated patients admitted to an ICU.

Design, Setting, and Participants

This retrospective cohort study on regional data sets reports: (1) daily number of administered vaccines and (2) data of all consecutive patients admitted to an ICU in Lombardy, Italy, from August 1 to December 15, 2021 (Delta variant predominant). Vaccinated patients received either mRNA vaccines (BNT162b2 or mRNA-1273) or adenoviral vector vaccines (ChAdOx1-S or Ad26.COV2). Incident rate ratios (IRRs) were computed from August 1, 2021, to January 31, 2022; ICU and baseline characteristics and outcomes of vaccinated and unvaccinated patients admitted to an ICU were analyzed from August 1 to December 15, 2021.

Exposures

COVID-19 vaccination status (no vaccination, mRNA vaccine, adenoviral vector vaccine).

Main Outcomes and Measures

The incidence IRR of ICU admission was evaluated, comparing vaccinated people with unvaccinated, adjusted for age and sex. The baseline characteristics at ICU admission of vaccinated and unvaccinated patients were investigated. The association between vaccination status at ICU admission and mortality at ICU and hospital discharge were also studied, adjusting for possible confounders.

Results

Among the 10 107 674 inhabitants of Lombardy, Italy, at the time of this study, the median [IQR] age was 48 [28-64] years and 5 154 914 (51.0%) were female. Of the 7 863 417 individuals who were vaccinated (median [IQR] age: 53 [33-68] years; 4 010 343 [51.4%] female), 6 251 417 (79.5%) received an mRNA vaccine, 550 439 (7.0%) received an adenoviral vector vaccine, and 1 061 561 (13.5%) received a mix of vaccines and 4 497 875 (57.2%) were boosted. Compared with unvaccinated people, IRR of individuals who received an mRNA vaccine within 120 days from the last dose was 0.03 (95% CI, 0.03-0.04; P < .001), whereas IRR of individuals who received an adenoviral vector vaccine after 120 days was 0.21 (95% CI, 0.19-0.24; P < .001). There were 553 patients admitted to an ICU for COVID-19 pneumonia during the study period: 139 patients (25.1%) were vaccinated and 414 (74.9%) were unvaccinated. Compared with unvaccinated patients, vaccinated patients were older (median [IQR]: 72 [66-76] vs 60 [51-69] years; P < .001), primarily male individuals (110 patients [79.1%] vs 252 patients [60.9%]; P < .001), with more comorbidities (median [IQR]: 2 [1-3] vs 0 [0-1] comorbidities; P < .001) and had higher ratio of arterial partial pressure of oxygen (Pao2) and fraction of inspiratory oxygen (FiO2) at ICU admission (median [IQR]: 138 [100-180] vs 120 [90-158] mm Hg; P = .007). Factors associated with ICU and hospital mortality were higher age, premorbid heart disease, lower Pao2/FiO2 at ICU admission, and female sex (this factor only for ICU mortality). ICU and hospital mortality were similar between vaccinated and unvaccinated patients.

Conclusions and Relevance

In this cohort study, mRNA and adenoviral vector vaccines were associated with significantly lower risk of ICU admission for COVID-19 pneumonia. ICU and hospital mortality were not associated with vaccinated status. These findings suggest a substantial reduction of the risk of developing COVID-19-related severe acute respiratory failure requiring ICU admission among vaccinated people.

Lung Biomolecular Profile and Function of Grafts from Donors after Cardiocirculatory Death with Prolonged Donor Warm Ischemia Time

The acceptable duration of donor warm ischemia time (DWIT) after cardiocirculatory death (DCD) is still debated. We analyzed the biomolecular profile and function during ex vivo lung perfusion (EVLP) of DCD lungs and their correlation with lung transplantation (LuTx) outcomes. Donor data, procurement times, recipient outcomes, and graft function up to 1 year after LuTx were collected. During EVLP, the parameters of graft function and metabolism, perfusate samples to quantify inflammation, glycocalyx breakdown products, coagulation, and endothelial activation markers were obtained. Data were compared to a cohort of extended-criteria donors after brain death (EC-DBD). Eight DBD and seven DCD grafts transplanted after EVLP were analyzed. DCD’s DWIT was 201 [188;247] minutes. Donors differed only regarding the duration of mechanical ventilation that was longer in the EC-DBD group. No difference was observed in lung graft function during EVLP. At reperfusion, “wash-out” of inflammatory cells and microthrombi was predominant in DCD grafts. Perfusate biomolecular profile demonstrated marked endothelial activation, characterized by the presence of inflammatory mediators and glycocalyx breakdown products both in DCD and EC-DBD grafts. Early graft function after LuTx was similar between DCD and EC-DBD. DCD lungs exposed to prolonged DWIT represent a potential resource for donation if properly preserved and evaluated.

A rare case of pneumatosis cystoides intestinalis with bowel perforation and secondary sepsis

MATERIALS AND METHODS

We present here the case of an 83 y.o. male with intestinal perforation from pneumatosis cystoides intestinalis and consequent sepsis.

RESULTS

The patient underwent urgency intestinal resection in our institute, with complete restitution ad integrum Discussion: Pneumatosis cystoides intestinalis is a rare affection, which can be categorized as primary (15%) or idiopathic( 85%). The clinical appearance can be very variable from patient to patient, since it can be completely asymptomatic or start with life-threatening clinical presentation of bowel perforation and sepsis. There are various theories about the formation of the gas bubbles trough the intestinal wall. The mechanical theory assumes that the gas, tearing trough the intestinal wall seeps trough it. The bacterial theory assumes that antibiotic treatment, such as with metronidazole, allows the creation of gas by microbiological elements like Clostridium Perfringens or Clostridium Difficile. The pulmonary theory, instead, assumes that air released from ruptured alveoli gets into the mediastinum and retro peritoneum, reaching the intestinal tract. The treatment is conservative most of the times, except for the cases of intestinal perforation and sepsis.

CONCLUSIONS

Despite of the long history of the disease, with the first description in 1783, little is known nowadays about PCI, due to the rarity of symptomatic disease. Further studies are needed to better evaluate the aetiology of the condition, and the prognostic criteria, which may be very important for clinical decisions about conservative or surgical treatment.

KEY WORDS

Diagnosis, Pneumatosis cystoides intestinalis, Peritonitis, Therapy.

Cholecystogastric fistula. A case report and literature review

Cholecystogastric fistulas is a rare complication of gallstone. Even if well described in the literature, this condition still poses a debate on diagnosis and surgical treatment. We present a case of a 35 year's old female which unexpectedly presented a cholecystogastric fistula during a laparoscopic cholecystectomy, treated successfully with fistula transection and repair and cholecystectomy through an open access. The open access remains the preferable option in this cases but laparoscopic techniques are being used worldwide with increasing success. The preoperative diagnosis remains difficult for the unspecific symptoms. KEY WORDS: Biliodigestive Fistula, Gallstone Ileus, Gastric Fistula, Biliary Fistula, Cholecystitis.

Secondary infections in critically ill patients with COVID-19

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .

Pleural Pressure Targeted Positive Airway Pressure Improves Cardiopulmonary Function in Spontaneously Breathing Patients With Obesity

BACKGROUND

Increased pleural pressure affects the mechanics of breathing of people with class III obesity (BMI > 40 kg/m²).

RESEARCH QUESTION

What are the acute effects of CPAP titrated to match pleural pressure on cardiopulmonary function in spontaneously breathing patients with class III obesity?

STUDY DESIGN AND METHODS

We enrolled six participants with BMI within normal range (control participants, group I) and 12 patients with class III obesity (group II) divided into subgroups: IIa, BMI of 40 to 50 kg/m²; and IIb, BMI of ≥ 50 kg/m². The study was performed in two phases: in phase 1, participants were supine and breathing spontaneously at atmospheric pressure, and in phase 2, participants were supine and breathing with CPAP titrated to match their end-expiratory esophageal pressure in the absence of CPAP. Respiratory mechanics, esophageal pressure, and hemodynamic data were collected, and right heart function was evaluated by transthoracic echocardiography.

RESULTS

The levels of CPAP titrated to match pleural pressure in group I, subgroup IIa, and subgroup IIb were 6 ± 2 cmH₂O, 12 ± 3 cmH₂O, and 18 ± 4 cmH₂O, respectively. In both subgroups IIa and IIb, CPAP titrated to match pleural pressure decreased minute ventilation (IIa, P = .03; IIb, P = .03), improved peripheral oxygen saturation (IIa, P = .04; IIb, P = .02), improved homogeneity of tidal volume distribution between ventral and dorsal lung regions (IIa, P = .22; IIb, P = .03), and decreased work of breathing (IIa, P < .001; IIb, P = .003) with a reduction in both the work spent to initiate inspiratory flow as well as tidal ventilation. In five hypertensive participants with obesity, BP decreased to normal range, without impairment of right heart function.

INTERPRETATION

In ambulatory patients with class III obesity, CPAP titrated to match pleural pressure decreased work of breathing and improved respiratory mechanics while maintaining hemodynamic stability, without impairing right heart function.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02523352; URL: www.clinicaltrials.gov.

Mechanical ventilation parameters in critically ill COVID-19 patients: a scoping review

BACKGROUND

The mortality of critically ill patients with COVID-19 is high, particularly among those receiving mechanical ventilation (MV). Despite the high number of patients treated worldwide, data on respiratory mechanics are currently scarce and the optimal setting of MV remains to be defined. This scoping review aims to provide an overview of available data about respiratory mechanics, gas exchange and MV settings in patients admitted to intensive care units (ICUs) for COVID-19-associated acute respiratory failure, and to identify knowledge gaps.

MAIN TEXT

PubMed, EMBASE, and MEDLINE databases were searched from inception to October 30, 2020 for studies providing at least one ventilatory parameter collected within 24 h from the ICU admission. The quality of the studies was independently assessed using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies. A total of 26 studies were included for a total of 14,075 patients. At ICU admission, positive end expiratory pressure (PEEP) values ranged from 9 to 16.5 cm of water (cmH₂O), suggesting that high levels of PEEP were commonly used for setting MV for these patients. Patients with COVID-19 are severely hypoxemic at ICU admission and show a median ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (PaO₂/FiO₂) ranging from 102 to 198 mmHg. Static respiratory system compliance (Crs) values at ICU admission were highly heterogenous, ranging between 24 and 49 ml/cmH₂O. Prone positioning and neuromuscular blocking agents were widely used, ranging from 17 to 81 and 22 to 88%, respectively; both rates were higher than previously reported in patients with "classical" acute respiratory distress syndrome (ARDS).

CONCLUSIONS

Available data show that, in mechanically ventilated patients with COVID-19, respiratory mechanics and MV settings within 24 h from ICU admission are heterogeneous but similar to those reported for "classical" ARDS. However, to date, complete data regarding mechanical properties of respiratory system, optimal setting of MV and the role of rescue treatments for refractory hypoxemia are still lacking in the medical literature.

The "Watch and wait" approach following chemoradiotherapy for rectal cancer: a case series and review of literature

Neoadjuvant chemoradiotherapy (NCRT) combined with total mesorectal excision (TME) is currently the gold standard for locally advanced low-lying rectal cancer (LACR). Around 20-30% of patients after NCRT can achieve clinical complete response (cCR); 5-44% of the patients who underwent TME achieve pathological complete response (pCR) on postoperative histopathologic studies. In the present study we perform a review of current Literature and retrospectively analyze our personal experience on "watch and wait" approach after cCR. Further studies are needed to establish an internationally accepted definition of clinical complete response, to delineate the real role of MRI in the post-treatment staging and to determine more precise predictors of sustained clinical complete response. The eventual presence of long-term morbidity and adverse effects after chemoradiation needs as well to be better evaluated. Evidence suggests that watch and wait approach is associated with substantially better quality of life and functional outcomes compared with standard surgical resection. KEY WORDS: Chemoradiation, Neoadjuvant therapy, Rectal cancer, Remission induction.

Preparedness of ICU networks for pandemics

PURPOSE OF REVIEW

The recent COVID-19 outbreak has clearly shown how epidemics/pandemics can challenge developed countries' healthcare systems. Proper management of equipment and human resources is critical to provide adequate medical care to all patients admitted to the hospital and the ICU for both pandemic-related and unrelated reasons.

RECENT FINDINGS

Appropriate separate paths for infected and noninfected patients and prompt isolation of infected critical patients in dedicated ICUs play a pivotal role in limiting the contagions and optimizing resources during pandemics. The key to handle these challenging events is to learn from past experiences and to be prepared for future occurrences. Hospital space should be redesigned to quickly increase medical and critical care capacity, and healthcare workers (critical and noncritical) should be trained in advance.

SUMMARY

A targeted improvement of hospital and ICU protocols will increase medical care quality for patients admitted to the hospital for any clinical reasons during a pandemic.

High Pleural Pressure Prevents Alveolar Overdistension and Hemodynamic Collapse in ARDS with Class III Obesity

Rationale: Obesity is characterized by elevated pleural pressure (Ppl) and worsening atelectasis during mechanical ventilation in patients with acute respiratory distress syndrome (ARDS).

Objectives: To determine the effects of a lung recruitment maneuver (LRM) in the presence of elevated Ppl on hemodynamics, left and right ventricular pressure, and pulmonary vascular resistance. We hypothesized that elevated Ppl protects the cardiovascular system against high airway pressure and prevents lung overdistension.

Methods: First, an interventional crossover trial in adult subjects with ARDS and a body mass index ≥ 35 kg/m² (n = 21) was performed to explore the hemodynamic consequences of the LRM. Second, cardiovascular function was studied during low and high positive end-expiratory pressure (PEEP) in a model of swine with ARDS and high Ppl (n = 9) versus healthy swine with normal Ppl (n = 6).

Measurements and Main Results: Subjects with ARDS and obesity (body mass index = 57 ± 12 kg/m²) after LRM required an increase in PEEP of 8 (95% confidence interval [95% CI], 7–10) cm H₂O above traditional ARDS Network settings to improve lung function, oxygenation and V./Q. matching, without impairment of hemodynamics or right heart function. ARDS swine with high Ppl demonstrated unchanged transmural left ventricular pressure and systemic blood pressure after the LRM protocol. Pulmonary arterial hypertension decreased (8 [95% CI, 13–4] mm Hg), as did vascular resistance (1.5 [95% CI, 2.2–0.9] Wood units) and transmural right ventricular pressure (10 [95% CI, 15–6] mm Hg) during exhalation. LRM and PEEP decreased pulmonary vascular resistance and normalized the V./Q. ratio.

Conclusions: High airway pressure is required to recruit lung atelectasis in patients with ARDS and class III obesity but causes minimal overdistension. In addition, patients with ARDS and class III obesity hemodynamically tolerate LRM with high airway pressure.

Clinical trial registered with www.clinicaltrials.gov (NCT 02503241).

A lung rescue team improves survival in obesity with acute respiratory distress syndrome

BACKGROUND

Limited data exist regarding ventilation in patients with class III obesity [body mass index (BMI) > 40 kg/m2] and acute respiratory distress syndrome (ARDS). The aim of the present study was to determine whether an individualized titration of mechanical ventilation according to cardiopulmonary physiology reduces the mortality in patients with class III obesity and ARDS.

METHODS

In this retrospective study, we enrolled adults admitted to the ICU from 2012 to 2017 who had class III obesity and ARDS and received mechanical ventilation for > 48 h. Enrolled patients were divided in two cohorts: one cohort (2012-2014) had ventilator settings determined by the ARDSnet table for lower positive end-expiratory pressure/higher inspiratory fraction of oxygen (standard protocol-based cohort); the other cohort (2015-2017) had ventilator settings determined by an individualized protocol established by a lung rescue team (lung rescue team cohort). The lung rescue team used lung recruitment maneuvers, esophageal manometry, and hemodynamic monitoring.

RESULTS

The standard protocol-based cohort included 70 patients (BMI = 49 ± 9 kg/m2), and the lung rescue team cohort included 50 patients (BMI = 54 ± 13 kg/m2). Patients in the standard protocol-based cohort compared to lung rescue team cohort had almost double the risk of dying at 28 days [31% versus 16%, P = 0.012; hazard ratio (HR) 0.32; 95% confidence interval (CI95%) 0.13-0.78] and 3 months (41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16-0.74), and this effect persisted at 6 months and 1 year (incidence of death unchanged 41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16-0.74).

CONCLUSION

Individualized titration of mechanical ventilation by a lung rescue team was associated with decreased mortality compared to use of an ARDSnet table.

High ligation of sapheno-femoral junction and thermal ablation for lower limb primary varicosity in day hospital setting

AIM

The traditional surgical treatment for lower limb primary varicosity has been for a long time high ligation of sapheno-femoral junction and stripping of great saphenous vein. Surgery, however, has been frustrated by postoperative pains and discomfort and recurrences so that it has been challenged by minimally invasive endovenous techniques such as laser treatment and radiofrequency ablation. The aim of the article is to assess the feasibility, in a day hospital setting, of a combined approach to greater saphenous vein reflux: high ligation of sapheno-femoral junction and thermal treatment of the great sapenous vein.

METHODS

A retrospective analysis on 95 patients treated with high ligation and thermal ablation at our institution from January 2009 to July 2017 was performed, assessing duration of surgery, post-operative pain and analgesics requirements, early complications and resumption of activities.

RESULTS

Two patients (2.74%), in the laser group experienced skin burns in the course of the GSV. Moderate ecchymosis, by laser fibre-induced perforation of the vein wall, were observed in another two patients (2.74%). Four limbs (5.48%) in the EVLT group developed transient paraesthesias. Analgesic requirement on POD 3 was nil for RFA group; conversely half of the EVLT patients did take analgesics, either 2 or 3 tabs were required. On POD 7, the patients of RFA group continued to not ask for any analgesics, but the same half of the patients in EVLT group still needed 1-2 tabs to carry out their normal activities smoothly. On POD 15, no patient did require analgesics. Resumption of routine activities was earlier for RFA group patients than for those in the EVLT group. The RFA group resumed their activities within 3 days, whereas EVLT group in 8-9 days. High ligation of the SFJ didn't add too much time or morbidities.

CONCLUSION

Catheter delivery of thermal energies for saphenous ablation, even when combined with high ligation of saphenous femoral arc, demonstrated to be minimally invasive, easy to learn and easy to perform in day hospital setting, with early return to normal activity. EVLT achieved similar results to RFA and both techniques were considered equally effective and safe; the results we obtained were not statistically significant but RFA showed less pain, ecchymosis and haematomas, as well as provided better short-term quality of life.

KEY WORDS

Day Hospital setting, Endovenous laser treatment, High ligation ablation of the saphenous vein, Radiofrequency ablation.

Amyand's hernia with acute phlegmonous appendicitis: case report

Any inguinal hernia containing the vermiform appendix is called Amyand's hernia. Amyand hernias are very rare and even rarer is the association of Amyand hernia with acute appendicitis. Due to the rarity of this entity, it constitutes a challenging case in terms of diagnosis and treatment. The surgical management is not yet standardized and there are no clear guidelines. There are some controversies regarding whether to perform an appendectomy if appendix appears normal or whether mesh can be used for the hernia repair if appendectomy is performed. We describe a case of Amyand hernia in a 90-year old man with acute appendicitis and we review current literature regarding surgical strategy.

Can Longo stapled haemorrhoidopexy for haemorroids be a day-case procedure?

We retrospectively collected data of 100 consecutives elective Longo's procedures for third- and fourth-degree simptomatic haemorroids, classified ASA grade I and II. All patients stayed overnight, because discharge was scheduled the day after the operation. 98 were discharged the day after the operation. Two patients were not discharged the day after because mild and severe bleeding respectively occurred during the first night after the operation which settled conservatively. All the patients were discharged on oral NSAID and stool softeners. None required rehospitalisation. Our retrospective study, pointing out that, in general patients did not require active intervention on the first postoperative night, represents an encouragement to introduce day-case stapled procedure for haemorroids.

Thermal ablation combined with high ligation of sapheno-femoral junction for lower limb primary varicosity

AIM

For long time the traditional surgical treatment for lower limb varicose veins has been high ligation of sapheno-femoral junction and stripping of great saphenous vein. Surgery, however, has been frustrated by postoperative pains, discomfort and recurrences so that it has been challenged by minimally invasive endovenous techniques such as laser treatment and radiofrequency ablation. The aim of the article is to assess the feasibility of a combined approach to greater saphenous vein reflux: high ligation of sapheno-femoral junction and thermal treatment of the great saphenous vein.

METHODS

A retrospective analysis on 95 patients treated with high ligation and thermal ablation at our institution was performed, assessing duration of surgery, post-operative pain and analgesics requirements, early complications and resumption of activities.

RESULTS

Two patients (5,4%), in the laser group experienced skin burns in the course of the GSV. Moderate ecchymosis, by laser fibre-Romainduced perforation of the vein wall, were observed in another two patients (5.4%). Four limbs (10.8%) in the EVLT group developed transient paraesthesias. Analgesic requirement on POD 3 was nil for RFA group; conversely half of the EVLT patients did take analgesics, either 2 or 3 tabs were required. On POD 7, the patients of RFA group continued to not ask for any analgesics, but the same half of the patients in EVLT group still needed 1-2 tabs to carry out their normal activities smoothly. On POD 15, no patient did require analgesics. Resumption of routine activities was earlier for RFA group patients than for those in the EVLT group. The RFA group resumed their activities within 3 days, whereas EVLT group in 8-9 days. High ligation of the SFJ didn't add too much time or morbidities.

CONCLUSION

High ligation of saphenous femoral arc combined with catheter delivered thermal energies for saphenous ablation, even when combined with high ligation of saphenous femoral arc, demonstrated to be minimally invasive, easy to learn and easy to perform, with early resumption and return to normal activity. EVLT achieved similar results to RFA and both techniques were considered equally effective and safe; the results we obtained were not statistically significant but RFA showed less pain, ecchymosis and haematomas, as well as provided better short-term quality of life.

Utility of continuous intraoperative neural monitoring in thyroid surgery in a low volume centre

This retrospective study, of a single surgeon's experience, evaluates the role of intraoperative neuromonitoring (IONM) for total thyroidectomy, in a low-volume district general hospital. 128 patients with normal preoperative vocal fold function underwent thyroid surgery with routine use of nerve monitoring. Patients were followed for 6 months after surgery, and postoperative Romanerve function was determined by fiberoptic laryngoscopy. One (0,8%) patient was found to have a unilateral vocal fold paralysis, but after 6 months this patient had regained vocal fold motion. The technique of intraoperative neuromonitoring in thyroid surgery is safe and reliable in excluding postoperative recurrent laryngeal nerve palsy; it has high accuracy, specificity, sensitivity and negative predictive value. Neuromonitoring is useful to identify the recurrent laryngeal nerve and it can be a useful adjunctive technique for reassuring surgeons of the functional integrity of the nerve. Its application can be particularly recommended for low-volume thyroid operation centres.

An Artificial Cough Maneuver to Remove Secretions From Below the Endotracheal Tube Cuff

BACKGROUND

Endotracheal suctioning is mandatory to prevent complications caused by the retention of tracheal secretions. Endotracheal suctioning is often performed late, when patients show signs of respiratory and hemodynamic alterations. We conceived a prototype device that, when synchronized with the ventilator, automatically removes secretions collected below the endotracheal tube (ETT) cuff, thus avoiding endotracheal suctioning. The aim of our investigation was to assess the performance of this novel prototype in vitro.

METHODS

Three studies were performed to examine the characteristics of the prototype. We tested device's ability to generate an effective artificial cough flow (artificial cough maneuver) > 1 L/s by rapidly deflating the ETT cuff within the time of a sustained inflation (at 30 and at 40 cm H₂O) (cough flow study). We also tested the prototype's ability to remove the fluid positioned below the ETT cuff using saline dye (fluid removal study), and to prevent the aspiration of saline dye from above the ETT cuff during the deflation phase of the ETT cuff (aspiration study). The trachea model was positioned at 45° in the aspiration study, and horizontally in the other two studies.

RESULTS

In the cough flow study, the prototype provided an effective artificial cough maneuver, with a mean ± SD of 1.78 ± 0.19 L/s (range, 1.42-2.14 L/s). The tracheal pressure after ETT cuff deflation never decreased below the PEEP level. In the fluid removal study, the prototype cleared the fluid from below the ETT cuff and the experimental trachea. No fluid was aspirated from the area above the ETT cuff toward the lower airways.

CONCLUSIONS

We conceived an system capable of automatically expelling fluid from below the ETT cuff outside an experimental trachea by generating an artificial cough maneuver. This system may decrease the use of endotracheal suctioning and its complications. Future in vivo studies are needed to confirm this first in vitro evaluation.

Public Prevention Plans to Manage Climate Change and Respiratory Allergic Diseases. Innovative Models Used in Campania Region (Italy): The Twinning Aria Implementation and the Allergy Safe Tree Decalogue

In recent years, climate change has been influenced by air pollution, and this destructive combination has justifiably sounded an alarm for nations and many institutional bodies worldwide. Official reports state that the emission of greenhouse gases produced by human activity are growing, and consequently also the average temperature. The World Health Organization (WHO) believes that health effects expected in the future due to climate change will be dramatic, and has invited international groups to investigate potential remedies. A task force has been established by the Italian Society of Allergology, Asthma and Clinical Immunology (SIAAIC), with the aim to actively work on correlation between pollution and climate change. The Task Force provided prevention tools to suggest city leaders how to improve the health conditions of allergic people in public urban parks. The "Allergy Safe Tree Decalogue" suggests the preparation and maintenance of public low allergy-impact greenery. Through the Twinning ARIA project, the Division for the Promotion and Enhancement of Health Innovation Programs of Campania Region (Italy), sought to promote the implementation of the project in the regional Health System. The main objective will be to investigate the current use and usefulness of mobile phone Apps in the management of allergic respiratory disease, through Mobile Airways Sentinel networK (MASK), the Phase 3 of the ARIA initiative, based on the freely available MASK App (the Allergy Diary, Android and iOS platforms). The effects of these prevention activities will be registered and compared with monitoring efforts thanks to the Aerobiology Units, located throughout the Campania area. A joint effort between researchers and public administrations for the implementation of prevention plans coherently with the two models proposed in a specific area, i.e. the Decalogue for public administrations and the MASK Allergy Diary app for individual patients suffering from allergy, will be implemented as a pilot.

Open inguinal hernia repair with self-gripping Parietex ProGrip mesh: a retrospective study of 204 cases

Chronic pain and recurrence rates are the main challenge in modern inguinal hernia surgery. Several trials have investigated the role of self-adhesive mesh repair for inguinal hernia, with special attention to the incidence of chronic postoperative inguinal pain and recurrence. The purpose of our study was to retrospectively evaluate the early and long-term results using a self-gripping mesh (Parietex Progrip® , Covidien) in our institution. A total of 204 patients, mean age 50.3 standard deviation (SD) 15.3, was included in the study. The repair was performed under local anaesthesia in 159 (78%) cases and locoregional anaesthesia in remaining 45 (22%). Mean operative time was 39 ± 20 minutes. The time for self-gripping mesh placement ranged from 5 to 9 minutes (mean 7 ± 2 minutes). There were no intraoperative complications. Clinical follow-up was performed at 1 month, 1 year and 2 years and consisted in the evaluation of complications, discomfort/pain and recurrence. One case of cutaneous infection and three cases of seroma were observed at one-month follow-up and were all treated conservatively. 8 patients were lost at one year follow-up, and another 4 were lost at 2 years. 3 patients died for other causes during follow-up. At 1 year and 2 years follow-up no cases of seroma, testicular complications or mesh infection were observed. Two cases of recurrence were recorded at 2 years follow up. No patient reported VAS score > 2 at one month, 1 year and 2 years follow-up. There were no readmissions, systemic complications or death during 2 years follow-up. Lichtenstein open repair using Parietex Progrip® mesh is a simple, rapid, effective and safe method for inguinal hernia repair. The main advantage of self-fixing mesh is the reduced operative time. A suturless fixation seems to prevent the development of postoperative chronic pain, without increasing recurrence rate in the majority of the trials.

Gravity modeling finds a large magma body in the deep crust below the Gulf of Naples, Italy

We analyze a wide gravity low in the Campania Active Volcanic Area and interpret it by a large and deep source distribution of partially molten, low-density material from about 8 to 30 km depth. Given the complex spatial-temporal distribution of explosive volcanism in the area, we model the gravity data consistently with several volcanological and petrological constraints. We propose two possible models: one accounts for the coexistence, within the lower/intermediate crust, of large amounts of melts and cumulates besides country rocks. It implies a layered distribution of densities and, thus, a variation with depth of percentages of silicate liquids, cumulates and country rocks. The other reflects a fractal density distribution, based on the scaling exponent estimated from the gravity data. According to this model, the gravity low would be related to a distribution of melt pockets within solid rocks. Both density distributions account for the available volcanological and seismic constraints and can be considered as end-members of possible models compatible with gravity data. Such results agree with the general views about the roots of large areas of ignimbritic volcanism worldwide. Given the prolonged history of magmatism in the Campania area since Pliocene times, we interpret the detected low-density body as a developing batholith.

Donors Thrombocytapheresis with Last Generation Cell Separators

An exciting, fast moving and promising field remains the use of plasma-free synthetic medium for platelet storage (10, 11), that along with the potential for getting more plasma for therapeutic needs, might also improve the quality of stored platelets. Addition of acetate to solution, may be the way to obtain these results. An astonishing fact is that citrate remains the only anticoagulant for platelet collection, and remains as well the only real cause of donor disconfort during thrombocytapheresis.

Plasma Exchange: The Cost/benefit Ratio and the Critical Revision of Indications

The number of conditions that can benefit from Plasma-Exchange (PE) continues to grow. We have recently added to the list the Cyclosporin-A induced hypertrygliceridemia and myoglobinuric acute renal insufficiency.

Such as any therapeutic measure for PE, four evolutive phases can be recognized: the discovery and research, the confirmation of indications, the routine applications and the decline, when new more powerful tools are offered by culture or technology. We have participated in the first three phases during the last 20 years.

Not necessarily all experiences were favourable. Nonetheless, we feel that, for the time being, a hemapheresis unit is an absolute necessity for a medium - sized hospital even if only therapeutic procedures are carried out. The phase four, decline of interest and applications, cannot be foreseen. Finally the ability of PE to shorten substantially the length of hospital stays along with the ease with which procedure can be performed on ambulatory patients, substantiate a favourable cost/benefit ratio for this therapeutic modality.

A Method for the Study of Cryoglobulin Solubilization Curves at 37°C. Preliminary Studies and Application to Plasma Exchange in Cryoglobulinemic Syndromes

A simple method for the study of kinetic solubility curves of cryoglobulins is presented. In its first application to the study of 21 patients with cryoglobulinemia, it was possible to ascertain that clinical condition roughly correlates with decreased solubility whereas no correlation is found with per cent cryocrit.

In the group of patients we studied, 6 underwent plasma exchange treatment when glomerulonephritis, acute renal insufficiency, cerebritis and polyneuropathy appeared: in these patients, following 2 to 5 apheretic sessions, solubility increased showing a sort of correlation with clinical benefits determined by treatment. The preliminarity of this study is underlined.

Cascade filtration: Clinical Application in 26 Patients with Immune Complex and Igm Mediated Diseases

A new technique which allows lymphocytapheresis to be combined with cascade filtration (CF) is described in this paper. This therapeutical approach was applied for the treatment of patients affected by necrotizing vasculitis (1), inflammatory myopathies (5), Cryoglobulinemia (5), immune complex polyneuropathies (7), rheumatoid arthritis (3) and psoriasis (3 patients). Two cases of Waldenstrom's macroglobulinemia were also treated after the onset of the hyperviscosity syndrome. 78 procedures have been performed without any untoward effect. From a clinical point of view all patients had some improvement following treatment, thereby confirming not only the clinical safety of this therapeutical approach but also its effectiveness at least in the management of diseases which usually respond to plasma exchange treatment. Laboratory investigations showed that with CF it is possible to selectively remove IgM, immune complexes, fibrinogen, lipoproteins and high molecular weight plasma components, sparing most albumin and IgG globulins (85 and 71%, respectively).

Acute Intravascular Hemolysis in Two Patients Transfused with Dry-Platelet Units Obtained from the Same ABO Incompatible Donor

Since 1989 we have been collecting dry-platelets on a routine basis. Dry-platelets are those collected along with 25–30 ml of contaminating plasma cell with separators such as the Amicus, AS 104 and the Excel Pro. Platelets are resuspended in non plasma media for storage and for at least 60 hours their viability and functionality are not impaired. In this article we report on two hemolytic crises determined by two O Rh D + units of single donor platelets (SPD) taken from the same donor in a double-apheresis session. The two split units were admistered to two A Rh D + patients suffering from metastatic breast cancer and severe aplastic anemia (SAA) respectively. In both cases the hemolytic reaction was of the intravascular type, with a drop in hemoglobin (Hgb) level from 8.6 to 5.4 and from 8.8 down to 5.3 g/dl respectively. From the patients’ RBC only α - agglutinins were eluted and donor's indirect antiglobulin test (IAT) was negative with extended panel RBCs. In the first case the clinical course after erythroexchange (Erex) was uneventful whereas in the second one, that suffering from SAA, after Erex, acute renal failure and shock did complicate the clinical course and the patient died seven days after the incriminated platelet transfusion.

Intraoperative Blood Salvage: A New Artificial Organ?

Optimal blood supply is critical to modern medical practice. Among the different possibilities of improving the quality and safety of blood, it is generally felt that autologous donation has played an important role and has contributed to changing transfusional practices, mainly since the appearance of HIV and HCV on the blood transfusion scene. At the San Martino Hospital Immunohematology Service, the autotransfusion era began in 1985. Autologous predeposit donation was the first to be introduced, followed by intentional perioperative hemodilution, intraoperative blood salvage with DFC apparatuses and lastly post-operative blood salvage. From about 200 autologous donations in 1985 we reached 5,372 in 1993 and more than 6,000 autologus donations are expected for 1994. Only 189 intraoperative blood salvages, were carried out in 1986, 593 in 1989, 1,207 in 1993 and more than 1,500 blood salvage sessions are anticipated for 1994. In the meantime, the total number of homologous RBC units employed in the Hospital dropped from 45,000 in 1985 to 18,000 in 1994, with the Onco-hematological Divisions using approximately 10,000 units of packed RBC.

Intraoperative Blood Salvage (IOBS) in Cardiac and Vascular Surgery

The extensive application of IOBS has permitted a great reduction in the use of homoglous transfusion which presently represents the largest field of application of autologous systems. In cardiac and vascular surgery, IOBS is particularly useful to the goal of preventing the transmission of viral disorders and other adverse effects related to homologous transfusions. The apparatuses for IOBS may also be used to perform hemodilution and sequestration of a desired amount of platelet rich plasma. The appropriate usage of drugs in perioperative period and the promotion of hemostasis with IOBS are important costituents for the correct transfusional management of the patient. The feasibility and safety of IOBS is known and in expert hands it is an optimal method for the transfusional treatment of surgical patients

Extragenital malignant mixed mesodermal tumor: A case report

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Primary peritoneal Malignant Mixed mesodermal tumor is an extremely rare and aggressive neoplasm with only few case reported in the literature.

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Recommendations for the treatment of MMMT are based on individual cases only.

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Surgical excision is the most effective treatment in carcinosarcomas.

Introduction

Primary malignant mixed mesodermal tumor (MMMt, also called malignant mixed Mullerian tumor and designated in the WHO classification of female genital tract neoplasms as carcinosarcoma) is an infrequent tumor that develops usually in the uterus and more rarely in the ovary. Extragenital tumor, including primary peritoneal MMMt, is an extremely rare and aggressive neoplasm with only few case reported in the literature.

Presentation of case

We report a case of a 70-year’s old female who presented with nausea and abdominal discomfort for 6 months. Workup revealed an abdominal mass. Patient was treated with surgical removal in a general hospital.

Discussion

Most peritoneal carcinosarcomas originate in the pelvic peritoneum, followed by decreasing frequency in the serosal surface of the colon, retroperitoneum, anterolateral abdominal peritoneum, and omentum. Surgical excision is the most effective treatment in carcinosarcomas. A complete cytoreduction, with resection of cancer to a status of no evidence of disease by the surgeon’s unaided eye should be attempted.

Conclusion

Owing to the rarity of the disease, limited data regarding the management of peritoneal MMMT exists. Recommendations for the treatment of MMMT are based on individual cases only. In our case, the patient is alive with a follow-up of 15 months and she did not receive any cycle of chemotherapy.

The adhesion molecule ICAM-1 is overexpressed in patients with Hymenoptera venom allergy and decreases after ultrarush venom immunotherapy

Adhesion molecules, including ICAM-1, are an important factor in allergic inflammation caused by inhalant allergens, but there are no studies investigating their possible role in Hymenoptera venom allergy (HVA). We measured the level of ICAM-1 in 13 venom-allergic patients before and after ultra-rush venom immunotherapy (VIT). Eight patients were treated by yellow jacket venom and 5 were treated by honeybee venom. Serum ICAM-1 levels were assayed by an immunoenzymatic method, with a detection limit of 0.35 ng/ml. The mean level of ICAM-1 changed from 316.4±78.2 ng/ml before VIT to 294.7±77.9 after VIT. This difference was statistically significant (p = 0.019). These findings show that in patients with HVA there is an over-expression of ICAM-1, and that ultra-rush VIT significantly decreases ICAM-1 levels. It is likely that the known ability of VIT to correct the imbalance in T lymphocytes subpopulations and in the associated production of cytokines may account for this observation. In fact, such cytokines include IL-4 and TNF-alpha, that up-regulate adhesion molecules.

Totally implantable central venous access devices in adult oncological patients

Totally implantable vascular access devices (ports) were introduced into clinical practice to replace external catheters in patients undergoing prolonged intravenous therapy. Today, they are also designed to provide repeated access to the vascular system for the delivery of blood products and are also used for the withdrawal of blood samples. As regards cancer patients, the availability of these continuous reliable intravenous catheterisation devices has provided an opportunity to deliver more complex, multi-drug regimens, in safety and with a good quality of life. One hundred and eight patients underwent the subcutaneous positioning of a totally implanted reservoir (via the right subclavian vein) for aggressive combination chemotherapy in an operating room suite, using local anaesthesia. No patients suffered from air embolism, severe bleeding, brachial plexus injury, cardiac tamponade, haemothorax or hydrothorax. No patients experienced catheter occlusion or catheter-related venous thrombosis. One patient suffered from a pocket infection. Two patients experienced pneumothorax, but neither of them required catheter removal or required chest drainage. Indications, contraindications and complications are discussed. With careful routine care, totally subcutaneously implanted ports are very safe and provide reliable access to the venous system.

Endovenous laser therapy combined with a surgical approach for primary varicose veins of the lower limbs

In recent years, the minimal invasive alternatives to surgical ligation and stripping for the treatment of an incompetent greater saphenous vein have been explored. Endovenous laser therapy (EVLT) is one of these therapeutic options. We report on our initial experience with endovenus laser therapy combined with a surgical approach. Over the period from September 2006 to September 2007, in the Colleferro City Hospital General Surgery Department, 19 patients were submitted to endovenous laser therapy combined with a surgical approach. We opted for a combined technique in which the use of the laser was preceded by high ligation of the saphenous vein ("crossectomy") together with complete sectioning of the venous collaterals. We observed no severe complications and endovenous laser therapy proved safe and easy to perform. However, this study is too limited and too short in terms of follow-up and number of patients to establish the superiority of the procedure over stripping in terms of recurrences. Endovenous laser therapy seems promising, but larger numbers and longer follow-up are needed to suggest this technique as the best approach to the management of varicose vein disease.

Pancreatic pseudocyst caused by extracorporeal shock wave lithotripsy for right renal pelvic calculi

A 39-year-old white man with a history of right renal pelvic stones treated 1 year before by extracorporeal shock wave lithotripsy, but with no history of major surgery, alcoholism, pancreatitis, hyperparathyroidism or trauma, was admitted, suffering from an abdominal mass. Abdominal and pelvic computed tomography revealed an enlarged pancreatic head (9 cm in transverse diameter) with, inside it, a heterogeneous, cyst-like structure, measuring 7 cm in diameter. It was suspected that this lesion was a cystic neoplasm and the patient underwent a proximal pancreaticoduodenectomy and a cholecystectomy. After the operation, the microscopic findings ruled out the presence of a neoplasm and we were obliged to reconsider the case. Speculating as to the possible role of past extracorporeal shock wave lithotripsy in determining the pancreatic pseudocyst, it was found that damage to the intra-abdominal organs during extracorporeal shock wave lithotripsy has been mentioned in published series, but it was also noted that this case seemed to differ from the other published cases, where cirrhosis and thrombocytopenia, gallbladder stones, or adhesions between the pancreas and surrounding tissue caused by laparotomy were considered the causes of the lithotripsy complications. We suggest a direct traumatic disruption of the pancreas as a result of the extracorporeal shock wave lithotripsy and conclude that the post-lithotripsy follow-up should include periodic ultrasonographic investigation of the pancreas and serum amylase level determinations in order to diagnose pancreatic complications, if any, and plan the correct treatment.