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Actinomycosis of the central nervous system is extremely rare. A 73-year-old woman with a history of abdominal actinomycosis presented with sudden-onset headache. Magnetic resonance imaging demonstrated a nodular lesion at the left precentral gyrus. A cerebral angiogram confirmed a fusiform aneurysm arising from the precentral branch of the left middle cerebral artery. High-resolution vessel wall imaging revealed circumferential wall enhancement of the aneurysm and multifocal enhancement of the M3 and M4 segments of both middle cerebral arteries. The patient had received a 4-week course of antibiotics, but follow-up angiography demonstrated no shrinkage or resolution of the aneurysm. Trapping combined with revascularization was successfully performed for refractory mycotic aneurysms.

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BACKGROUND: Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines. METHODS: The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020. RESULTS: The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible. CONCLUSIONS: The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.

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BACKGROUND: Acute pancreatitis is a common inflammatory pancreatic disorder, often caused by gallstone disease and frequently requiring hospitalization. In 80% of cases, a rapid and favourable outcome is described, while a necrosis of pancreatic parenchyma or extra-pancreatic tissues is reported in 10-20% of patients. The onset of pancreatic necrosis determines a significant increase of early organ failure rate and death that has higher incidence if infection of pancreatic necrosis (IPN) or extra-pancreatic collections occur. IPN always requires an invasive intervention, and, in the last decade, the advent of minimally invasive techniques has gradually replaced the employment of the open traditional approach. We report a series of three severe cases of IPN managed with primary open necrosectomy (ON) and a systematic review of the literature, in order to understand if emergency surgery still has a role in the current clinical practice. METHODS: From January 2010 to January 2020, 3 cases of IPN were treated in our Academic Department of General and Emergency Surgery. We performed a PubMed MEDLINE search on the ON of IPN, selecting 20 from 654 articles for review. RESULTS: The 3 cases were male patients with a mean age of 61.3 years. All patients referred to our service complaining an evolving severe clinical condition evocating a sepsis due to IPN. CT scan was the main diagnostic tool. Patients were initially conservatively managed. In consideration of clinical worsening conditions, and at the failure of conservative and minimal invasive treatment, they were, finally, managed with emergency ON. Patients reported no complications nor procedure-related sequelae in the follow-up period. CONCLUSION: The ON is confirmed to be the last resort, useful in selected severe cases, with a defined timing and in case of proven non-feasibility and no advantage of other minimally invasive approaches.

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PURPOSE: The objective of this study was to investigate the accuracy of 18F-FDG-PET in the diagnosis of multibacterial abdominal sepsis by cecum ligation and puncture (CLP) in rats. METHODS: Adult Wistar rats ( Rattus norvegicus ), weighing 227±35g, were allocated into a sepsis group by CLP (n=10) and sham group (n=10). 18F-FDG-PET using microPET was performed on all rats after 24 hours. RESULTS: All animals survived for postoperative 24h. The abdomen/liver ratio of the standardized uptake value (SUV) percentage was significantly higher in the sepsis group than in the sham (p=0.004). The ROC curve showed an accuracy of 18F-FDG-PET to detect abdominal sepsis of 88.9% (p=0.001), sensitivity of 90% and specificity of 88.9%. When a cut-off point of 79% of the ratio between the SUV on the abdominal region and liver was established, the sensitivity was 90%, specificity of 88.9%; positive and negative predictive values of 90.0% and 88.9%, respectively. CONCLUSIONS: The diagnostic accuracy of 18F-FDG-PET in rats with abdominal sepsis was significantly high. It was also demonstrated the predictive ability of the abdomen/liver SUV ratio to diagnose abdominal sepsis. These findings may have implications for the clinical setting, locating septic foci with PETscan.

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Introducción: las peritonitis, proceso inflamatorio general o localizado de la membrana peritoneal; traen consigo una serie de trastornos locales intraabdominales y generales que amenaza la vida del paciente de manera potencial, dejada sin tratamiento más del 90 por ciento de los pacientes mueren. Objetivo: evaluar la utilidad de variables clínicas, humorales e imaginológicas postoperatorios, vitales para el diagnóstico precoz de la infección intraabdominal persistente. Método: se realizó un estudio observacional analítico, de cohorte, prospectivo y longitudinal en 45 pacientes mayores de 15 años intervenidos quirúrgicamente por peritonitis secundaria supurada difusa (PSSD) y que fueron reintervenidos con la impresión diagnóstica de peritonitis persistente de los cuales unos la desarrollaron y otros no, en el período comprendido de septiembre del 2014 hasta abril del 2018. Resultados: para el diagnóstico precoz de las peritonitis persistentes en pacientes operados de peritonitis supuradas; la frecuencia cardiaca prereintervención, el dolor abdominal espontáneo posoperatorio mantenido en las primeras 48 horas y el dolor posoperatorio a la descompresión del abdomen fueron los hallazgos más significativos. Conclusiones: el dolor posoperatorio a la descompresión del abdomen adquirió valor predictivo de reintervención para las primeras 48 horas de operado y su aparición incrementó en 6 veces el riesgo de presentar una peritonitis persistente(AU)

Introduction: peritonitis, general or localized inflammatory process of the peritoneal membrane; they bring with them a series of local intra-abdominal and general disorders that threatens the patient's life in a potential way, left untreated more than 90 percent of patients die. Objective: to evaluate the usefulness of postoperative clinical, humoral and imaginological variables, vital for the early diagnosis of persistent intra-abdominal infection. Method: An analytical, cohort, prospective and longitudinal observational study was carried out in 45 patients older than 15 years undergoing surgery for diffuse suppurative secondary peritonitis (PSSD) and who were reoperated with the diagnostic impression of persistent peritonitis of which some developed and others do not, in the period from September 2014 to April 2018. Results: For the early diagnosis of persistent peritonitis in patients operated with suppurative peritonitis, prereintervention heart rate, postoperative spontaneous abdominal pain maintained in the first 48 hours and post-operative pain after abdominal decompression were the most significant findings. Conclusions: the postoperative pain to decompression of the abdomen acquired a predictive value of reoperation for the first 48 hours of surgery and its appearance increased by 6 times the risk of presenting a persistent peritonitis(EU)

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BACKGROUND: Percutaneous or endoscopic drainage was usually performed as the first step in step-up approach for infected pancreatic necrosis (IPN). However, drainage was unnecessary or unavailable in some patients. OBJECTIVE: To estimate the safety and effect of one-step laparoscopic-assisted necrosectomy in IPN patients. METHODS: A retrospective analysis of IPN patients received surgical therapy in our center between January 2015 and December 2017 was performed. Patients were assigned to either one-step or step-up groups according to the received therapeutic approach. Incidence of complications, death, total number of interventions, and total hospital stay were compared. Logistic regression and nomogram were used to explore the risk factors and probability for patients undergoing interventions ≥3 times. RESULTS: There were 45 and 49 patients included in one-step and step-up groups, respectively. No significant difference between groups in terms of new organ failure (14.29 vs. 14.33%, p = 0.832), death (8.89 vs.8.17%, p = 0.949), and long-term complications (18.37 vs. 15.56%, p = 0.717). However, the number of interventions in one-step group was significantly less than in step-up group with shorter hospital stay. After multivariate analysis, C-reactive protein, interleukin-6, and surgical approach were independent predicators for patients undergoing interventions ≥3. A nomogram was built with area under ROC curve 0.891. CONCLUSION: Compared with step-up approach, one-step surgery was safe and effective in selected IPN patients with less interventions and shorter hospital stay.

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Abstract Purpose The objective of this study was to investigate the accuracy of 18F-FDG-PET in the diagnosis of multibacterial abdominal sepsis by cecum ligation and puncture (CLP) in rats. Methods Adult Wistar rats ( Rattus norvegicus ), weighing 227±35g, were allocated into a sepsis group by CLP (n=10) and sham group (n=10). 18F-FDG-PET using microPET was performed on all rats after 24 hours. Results All animals survived for postoperative 24h. The abdomen/liver ratio of the standardized uptake value (SUV) percentage was significantly higher in the sepsis group than in the sham (p=0.004). The ROC curve showed an accuracy of 18F-FDG-PET to detect abdominal sepsis of 88.9% (p=0.001), sensitivity of 90% and specificity of 88.9%. When a cut-off point of 79% of the ratio between the SUV on the abdominal region and liver was established, the sensitivity was 90%, specificity of 88.9%; positive and negative predictive values of 90.0% and 88.9%, respectively. Conclusions The diagnostic accuracy of 18F-FDG-PET in rats with abdominal sepsis was significantly high. It was also demonstrated the predictive ability of the abdomen/liver SUV ratio to diagnose abdominal sepsis. These findings may have implications for the clinical setting, locating septic foci with PETscan.

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INTRODUCTION: Intra-abdominal infections remain a leading cause of death, morbidity and resource use in surgical wards and intensive care units. The growing complexity of their management has led to new paradigms and unresolved issues in anti-infective therapy described in the current review. Areas covered: We analyzed the literature, recent guidelines, and expert opinions published over the last decade. Expert commentary: Prospective randomized trials are difficult to perform and observational studies or database analyses should be encouraged. Epidemiologic and microbiologic reports should be promoted, especially in developing/resource-limited countries and in specific subpopulations such as children, older people and patients with underlying diseases. The diagnostic process, including imaging procedures, could be improved. The value of biomarkers for diagnosis, monitoring and discontinuation of therapy should be clarified and improved. New microbiologic techniques are needed to speed up the diagnostic process and to improve the adequacy of anti-infective therapy. Very little progress has been made in the detection of clinical failures. Many aspects of anti-infective management, both for bacteria and fungi, remain unresolved, such as the high inoculum, the type of microorganisms to be treated, the timing of therapy, the value of de-escalation, drug monitoring and duration of therapy. New antibiotics are expected.

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PURPOSE:: To examine a correlation of micro-PET images with photographic images of the digestive organs in abdominal sepsis model. METHODS:: Male Wistar rats weighing 265±18g were used. Abdominal sepsis was induced by ligature and cecal puncture. Micro-PET Images from abdominal cavity septic foci were obtained using 18-Fluoro-deoxyglucose, looking for a correlation with photographic images of abdominal cavity organs. Pearson's correlation test was used. RESULTS:: The mean standard uptake values (SUV) and lesion areas were 2.58±0.63SUVbwg/ml and 546.87±300.95mm2, respectively. There was a strong positive correlation between the two variables (r=0.863, p=0.137), which resulted in a coefficient of determination r2?0.75, meaning that 75% of SUV variation is explained by the lesion areas of digestive organs. CONCLUSION:: Micro-PET allows high throughput assessment of lesion count and volume in pre-clinical rat model of CPL abdominal sepsis.

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Abstract Purpose: To examine a correlation of micro-PET images with photographic images of the digestive organs in abdominal sepsis model. Methods: Male Wistar rats weighing 265±18g were used. Abdominal sepsis was induced by ligature and cecal puncture. Micro-PET Images from abdominal cavity septic foci were obtained using 18-Fluoro-deoxyglucose, looking for a correlation with photographic images of abdominal cavity organs. Pearson's correlation test was used. Results: The mean standard uptake values (SUV) and lesion areas were 2.58±0.63SUVbwg/ml and 546.87±300.95mm2, respectively. There was a strong positive correlation between the two variables (r=0.863, p=0.137), which resulted in a coefficient of determination r2?0.75, meaning that 75% of SUV variation is explained by the lesion areas of digestive organs. Conclusion: Micro-PET allows high throughput assessment of lesion count and volume in pre-clinical rat model of CPL abdominal sepsis.

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BACKGROUND: Although there is a wealth of information predicting risk of post-operative intra-abdominal collection and guiding antibiotic therapy following appendicectomy, confusion remains because of lack of consensus on the clinical severity and definition of 'complicated' appendicitis. This study aimed to develop a standardized intra-operative grading system: Sunshine Appendicitis Grading System (SAGS) for acute appendicitis that correlates independently with the risk of intra-abdominal collections. METHODS: Two-hundred and forty-six patients undergoing emergency laparoscopy for suspected appendicitis were prospectively scored according to the severity of appendicitis and followed up for complications including intra-abdominal collection. After termination of the study, the SAGS score was repeated by an independent surgeon based on operation notes and intra-operative photography to determine inter-rater agreement. The primary outcome measure was incidence of intra-abdominal collection, secondary outcome measures were all complications and length of stay. RESULTS: SAGS score demonstrated good inter-rater agreement (kappa Kw 0.869; 95% CI 0.796-0.941; P < 0.001). A risk ratio of 2.594 (95% CI 0.655-4.065; P < 0.001) for intra-abdominal collection was found using SAGS score as a predictor. The discriminative ability of SAGS score was supported by an area under the curve value of 0.850 (95% CI 0.799-0.892; P < 0.001). CONCLUSIONS: SAGS score can be used to simply and accurately classify the severity of appendicitis and to independently predict the risk of intra-abdominal collection. It can therefore be used to stratify risk, guide antibiotic therapy, follow-up and standardize the definitions of appendicitis severity for future research.

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OBJECTIVES: 67Ga-Citrate has been extensively used for infection and inflammation imaging for the past four decades but has limitations. In the present study, we explored the ability of 68Ga-Citrate to detect Staphylococcus aureus (Staph A) infection in rats and further studied its ability to localize intra-abdominal infection in a patient. METHODS: An infection was induced in male Wistar rats by injecting Staph A in the right thigh muscle. In this study a simple method was described for the preparation of 68Ga-Citrate with > 99% yield and purity. 68Ga-Citrate (15 MBq/rat and 150 MBq/patient) was injected intravenously and the images were acquired for 10 min each. RESULTS: 68Ga-Citrate uptake was moderate at the infection lesion within 5 min post injection but intense focal uptake was visualized from 30 min to 6 hr post-injection in rats. Cardiac blood pool and liver activity decreased during the same period of study. In the patient studied, an infected area in the abdomen at the site of recent appendectomy was detected within 30min post-injection of 68Ga-Citrate, which was consistent with CT and microbiology findings. CONCLUSION: A simple method of preparation of 68Ga-Citrate with > 99% yield and purity was described, suitable for routine clinical work. Our results showed 68Ga-Citrate is capable of detecting Staph A infection in rats and an intraabdominal infection in a post-operative patient. These findings indicate the high potential of 68Ga-Citrate for clinical utility.

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