Abstracts from the Twenty-fifth European Congress on Surgical Infection Lund,Sweden June 13–16,2012

1 Academic Medical Center, University of Amsterdam 2 Kennemer Gasthuis Haarlem Netherlands 3 St. Vincent's University Hospital, Dublin, Ireland 1. OVERTREATMENT OF COLONIC DIVERTICULITIS: A PLEA FOR A LESS AGGRESSIVE APPROACH

Background: Despite the fact there still is controversy about the appropriate management of the various stages of diverticulitis and its complications, one cannot help but noticing a shift away from invasive, operative treatment for both complicated and uncomplicated disease towards a less aggressive, non-operative approach. This shift is congruent with expanding evidence on optimal treatment and an increasing understanding diverticulitis comprises different disease entities with heterogeneity between patients.

Aim: In this study we present an overview of the development in treatment of colonic diverticulitis and address the available evidence for contemporary operative and non-operative management.

Methods: Literature search in Medline and Embase.

Results: The standard of care for perforated or complicated diverticulitis evolved from a Hartmann's procedure, to resection and primary anastomosis, to treatment with antibiotics and percutaneous drainage in a carefully selected patient subset. Recently laparoscopic lavage emerged as a promising treatment for Hinchey 3 cases. Likewise for uncomplicated diverticulitis the approach is becoming less aggressive with a change from intravenous antimicrobial therapy, starvation and admission, to oral antibiotics and finally to observation and outpatient treatment.

Conclusions: One might say we overtreated the majority of diverticulitis patients for decades. Avoidance of overtreatment has obvious benefits: less in hospital treatment, cost reduction, less antimicrobial resistance, reduction in complication rate and side effects and presumably a better quality of life. In the nearby future hopefully several unanswered questions regarding the pathogenesis and optimal management of different diverticulitis stages will be answered by various ongoing trials.

1 Skåne University Hospital, Lund, Sweden 2 Skåne University Hospital, Malmö, Sweden 2. ADHESIVE SMALL BOWEL OBSTRUCTION FOLLOWING OPEN VERSUS LAPAROSCOPIC SURGERY FOR SUSPECTED APPENDICITIS—IS THERE A DIFFERENCE IN INCIDENCE?

Background: Appendicitis is a common surgical diagnose with a lifetime risk of approximately 7%. Appendectomy is the treatment chosen for most patients. Postoperative adhesions are common following abdominal surgery including appendectomy.

Aim: The aim of the present study was to compare the frequency of readmission for small bowel obstruction following open surgery versus laparoscopic surgery for suspected appendicitis.

Methods: All patients, >/=16 years, who had open appendectomy performed at Skåne University Hospital in Lund and all patients (same age) that underwent laparoscopic surgery for suspected appendicitis at Skåne University Hospital in Malmö between 1992 and 2007 were included. All patients' charts were retrospectively and individually studied and followed up until the end of 2009. Rehospitalization for small bowel obstruction, >/=30 days after index surgery, were registered.

Results: 2332 patients in the open group (OG) and 2372 patients in the laparoscopic group (LG) were included. The frequency of readmission leading to hospitalization for small bowel obstruction was low in both groups. A difference between the groups (0.7% in the OG and 0,3% in the LG) were identified but showed no statistical significance, p=0.06.

Conclusions: There was no significant difference in readmission between the two groups. There was a tendency towards less postoperative small bowel obstruction following laparoscopic surgery for suspected appendicitis.

1 Department of Surgery, Skåne University Hospital, Lund, Sweden 2 Department of Surgery, Karolinska University Hospital, Stockholm 3 Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden 1 Department of Surgery, Skåne University Hospital, Lund, Sweden 3. SURVEY OF THE MANAGEMENT OF ACUTE PANCREATITIS IN SWEDEN

Background: Several international guidelines concerning treatment of acute pancreatitis (AP) has been published during the last decades. However, Scandinavian guidelines are still missing.

Aim: The aim was to identify current treatment strategies for AP in Sweden, and to evaluate if there is a need for improvement.

Methods: A questionnaire was e-mailed to the surgical department at all Swedish hospitals (n=58) taking care of patients with AP. Comparisons were made between university and non-university hospitals, and between hospitals with a primary catchment area of more versus less than150,000 persons.

Results: Fifty-one hospitals responded (88%). In median 65 (12-200) patients with AP are treated yearly at each hospital. 18/51 performs a severity classification, with APACHE II being the most commonly used. A majority is of the opinion that a scoring system is not better than the judgement of a senior consultant. In severe AP, 29/48 administer antibiotics, 29/48 enteral nutrition and 25/49 have a standardized follow-up plan. In 29 hospitals ≥1 necrosectomies are performed yearly. The majority considered administration of intravenous fluids as the most important treatment in severe AP. After mild biliary AP, the corresponding answer was cholecystectomy, being more common at larger hospitals (p=0.002). 42/47 hospitals were interested in creating a Scandinavian quality register.

Conclusions: The results from this first Swedish national survey give a clear insight in current traditions of treatment of AP. We identified a lack of early severity stratification, limited use of enteral nutrition, and difference in standard care between hospitals.

1 Department of Clinical Sciences Malmö, Skåne University Hospital, Section of Surgery, Lund University 2 Department of Clinical Sciences, Vascular Excitation-Transcription Coupling, Lund University, Malmö 3 Department of Clinical Sciences, Molecular Metabolism, Lund University, Malmö Sweden 4 Department of Physiology, Nursing School, University of Extremadura, Caceres Spain 6. NFATc3 REGULATES TRYPSINOGEN ACTIVATION, NEUTROPHIL RECRUITMENT, AND TISSUE DAMAGE IN ACUTE PANCREATITIS IN MICE

Background: Acute pancreatitis (AP) is an inflammatory disease with a wide clinical spectrum. Elevated cytosolic calcium, trypsinogen activation and inflammation are key components in the pathophysiology of AP but the molecular mechanisms leading to the initiation and propagation of these events are still unclear.

Aim: To explore the potential involvement of the calcium/calcineurin-dependent transcription factor nuclear factor of activated T- cells (NFAT) in AP.

Methods: Retrograde infusion of sodium taurocholate into the pancreatic duct of mice caused a severe AP characterized by elevated blood amylase, pancreas and lung myeloperoxidase (MPO), pancreas macrophage inflammatory protein-2 (CXCL2), trypsinogen activation and severe tissue destruction (acinar cell necrosis, edema, leukocyte infiltration and hemorrhage) in the pancreas.

Results: In transgenic NFAT-luciferase (NFAT-luc) reporter mice NFAT-dependent transcriptional activity was significantly increased in pancreas, as well as in aorta, lung and spleen after taurocholate challenge. Treatment with the NFAT inhibitor A-285222 completely blocked taurocholate-induced NFAT activation in all organs and led to restored levels of inflammatory mediators as well as preserved tissue architecture. Similarly, NFATc3-deficient mice were protected from taurocholate-induced trypsinogen activation, inflammation and destruction of pancreatic tissue. Secretagogue-induced activation of trypsinogen in acinar cells ex vivo was also NFAT-dependent, since pharmacological inhibition with A-285222 or lack of NFATc3 protein abolished the response.

Conclusions: Our data suggests that NFATc3 is a critical regulator of trypsinogen activation, neutrophil recruitment and pancreatic tissue damage and may be a potential therapeutic target in AP.

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Fig. 1.

Effects 24 hours after taurocholate infusion in the pancreatic duct in wildtype (NFATc3+/+) and NFATc3 knock out mice. #=p<0.05 vs saline infused control and ¤=p<0.05 vs wildtype taurocholate challenged mice. Bars represent mean and SEM.

1 Society of Anaestesiology and Intensive Care Swedish Surgical Society Sweden 9. PROPHYLACTIC USE OF PROBIOTICS FOR REDUCTION OF SECONDARY INFECTIONS

Background: Avoiding secondary infections for surgical as well as for other patient categories is a major issue for the intensivist. As the frequency of multi resistant bacteria is increasing and driven by the use of antibiotics, the demand for alternative and complementary treatments and prophylaxis increases. The easiest way of treating an infection is by avoiding it. Effective prophylactic procedures result in fewer infections.

Ventilator associated pneumonia (VAP) is a frequent complication to intensive care and causes increases in human suffering, costs, prolonged ICU and hospital stay, and prolonged antibiotics therapies. Aspiration of infected secretions from the oropharynx to the lungs is the main cause of VAP and reduction of pathogenic bacteria through oral care is of vital importance.

Aim: To compare the effectiveness of an established procedure for oral care to an ecologic alternative procedure.

Methods: Prospective randomized multicenter study. The established use of the antiseptic chlorhexidine (CHX) soaked swabs is compared to the application of the probiotic bacterium Lactobacillus plantarum 299. Cultures from oropharynx and tracheal secretions are analyzed. Daily routine chemistry.

Results: Demografic and ICU-admission data are similar. CRP is lower in the probiotic group from day 3. Difference is not significant; WBC values are similar. In the CHX group, emerging pathogens were cultured from 57% cent in oropharyngeal samples and 38% in the probiotic group.

Conclusions: This biologic method is at least as effective as the established procedure using the antiseptic chlorohexidine in prohibiting emerging enteric bacteria to establish in the oropharynx.

1 Lund University, Sweden 2 University of Copenhagen, Denmark 10. INFECTED SYNTHETIC MESHES AFTER INCISIONAL HERNIA MESH REPAIR CAN BE SALVAGED USING NEGATIVE PRESSURE WOUND THERAPY (NPWT)

Background: Mesh-infection has often led to mesh-explantation in order to cure infection and heal the wound. NPWT has become commonplace in treatment of difficult wounds but reports on NPWT of infected meshes are few.

Aim: The aim was to evaluate the result of NPWT of mesh-infection.

Methods: Records for patients treated with NPWT, after incisional hernia repair during 2010, were reviewed retrospectively.

Results: Eleven patients (10 females and one male), with heavy-weight polypropylene mesh repair were included. Ten healed while because one patient still has a small wound residue after two years, which has recently been revised and sutured since severe concomitant disease prevented earlier intervention. Four of the five secondary sutured patients healed without complications and one had a small wound relapse that healed after a month. In the other five successfully healed patients, NPWT was terminated when fresh granulations were encountered and the treatment continued with other wound dressings. All patients had positive cultures at the time of initiating NPWT and also at the time NPWT was terminated, including the patients whose wounds were secondary sutured. No mesh was partially or totally explanted.

Conclusions: Infected mesh can be salvaged with NPWT. Median time needed for wound healing was almost four months in the total group. Secondary suturing of the wound seems to shorten time to healing without major complications. We propose a regimen of initial NPWT and secondary suture as soon as granulation tissue is present in a macroscopically clean wound.

1 Dept of Critical Care Medicine, Ghent University Hospital 2 Dept of Surgery, Ghent University Hospital, Belgium 11. CHARACTERISTICS OF CLINICAL STUDIES EVALUATING ANTIBIOTIC THERAPY FOR INTRA-ABDOMINAL INFECTIONS: ASYSTEMATIC REVIEW

Background: Multiple studies have been performed to determine the efficacy of antimicrobial agents in treating IAI, but there may be considerable variation in infections included as well as reporting of these studies.

Aim: To analyze prospective studies on antibiotic treatment of IAI and compare patients and infections included, as well as evaluate the reporting in the studies.

Methods: A PubMed search (1949-2010) was used to identify prospective studies on the antibiotic treatment of IAI. These studies were evaluated for specific criteria such as inclusion criteria and patient and infection characteristics, as well as the reporting of these and outcome parameters.

Results: 74 studies were included in the analysis. Detailed reporting of the focus of infection was absent in 26% of the studies. When reported, the focus of IAI was highly variable, with the appendix being the most frequent focus (39%±21.2%). Only 33 studies (46%) reported outcomes of the microbiological evaluable population. Median success rate was around 86% (IQR 78%-93%). Severity of illness was specified in 48 studies (65%), but overall severity was low.

Conclusions: In studies on IAI, there is considerable variability in included patients and diseases, and multiple deficits exist in the reporting of the data. This limits proper interpretation of some studies, makes comparison of several studies difficult and restricts application of the results of these trials in clinical practice.

1 University of Nagoya 1 Toyota Kosei Hospital 2 Tokai Hospital 3 Yamashita Hospital 4 Chubu Rosai Hospital 5 Yachiyo Hospital 6 Shizuoka Saiseikai General Hospital, Japan 15. RISK FACTORS FOR INCISIONAL HERNIA IN ASSOCIATION WITH SURGICAL SITE INFECTIONS IN ABDOMINAL SURGERY: A LARGE MULTIPLE-INSTITUTIONAL PROSPECTIVE STUDY

Background: Incidence rate of incisional hernia (IH) in associated with surgical site infection (SSI) after abdominal surgery is not fully investigated.

Aim: The purpose of this study was to identify risk factors for IH in abdominal surgery, especially in association with SSIs.

Methods: From November 2009 to February 2011, we prospectively collected 3892 consecutive patients who underwent abdominal surgery for gastrointestinal, colorectal, and hepato-biliary-pancreatic diseases in the Division of Surgical Oncology, Department of Surgery, Nagoya University, and 18 affiliated hospitals. Patients were followed up for >180 days after operation to evaluate the incidence of SSI and incisional hernia.

Results: The incidence of overall SSI, superficial/deep incisional SSI (SD-SSI), and organ space SSI were 18.5%, 9.0%, and 10.9%, respectively. Wound dehiscence occurred in 350 patients (9.0%), and most of these patients had concomitant SD-SSI. Postoperative IH within 180 days occurred in 127 patients (3.3%). In univariate analysis, risk factors for IH were age, body mass index, American Society of Anesthesiology score, history of making colostomy, previous usage of anticancer drugs, emergency operation, wound classification, blood transfusion, suture materials for fascial closure, incidence of SDSSI, and depth of wound dehiscence. Independent risk factors for IH by multivariate analysis were age, suture materials for fascial closure, depth of wound dehiscence, and body mass index.

Conclusions: To reduce the incidence of incisional hernia, it is crucial to prevent SD-SSI and wound dehiscence.

1 Toyohasi Municipal Hospital 2 Nagoya Daiichi Red Cross Hospital 3 Nagoya Daini Red Cross Hospital 4 Handa City Hospital 5 Tsushima City Hospital 6 Chukyo Hospital 7 University of Nagoya, Japan 17. RISK FACTORS FOR SURGICAL SITE INFECTION IN ABDOMINAL SURGERY IN JAPAN. A MULTI-INSTITUTIONAL PROSPECTIVE STUDY

Background: The incidence of surgical site infection (SSI) has a great impact on patients' outcome and economic perspective.

Aim: The purpose of this study was to identify risk factors for SSI in abdominal surgery by performing a large multiple-institutional prospective data collection.

Methods: From November 2009 to February 2011, we prospectively collected 4305 consecutive patients who underwent abdominal surgery for gastrointestinal, colorectal, and hepato-biliary-pancreatic diseases in the Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, and 18 affiliated hospitals.

Results: The Incidence of overall SSI, superficial/deep incisional SSI (SD-SSI), and organ/space SSI (OSSSI) were 19.2%, 9.1%, and 11.7%, respectively. Postoperative hospital stay with overall SSI (38±27 days), SD-SSI (32±23 days), or OS-SSI (32±29 days) was significantly longer than that without any SSI (16±11 days). Independent risk factors for SD-SSI by multivariate analysis were liver cirrhosis, history of previous abdominal operation, emergency operation, wound length, usage of wound protector, and suture material for fascial closure. Independent risk factors for OS-SSI were male gender, American Society of Anesthesiology score, history of previous abdominal operation, operation time, blood loss, wound classification, and types of operation.

Conclusions: It is crucial to practice CDC guidelines as well as to make an effort to reduce operation time and blood loss, in order to prevent the incidence of SSI.

1 Hospital Universitari Mutua de Terrassa, Spain 2 University of Milan, Italy 3 AstraZeneca Spain 4 AstraZeneca Europe, Belgium 5 Instat Services, United States 6 University Hospital Munich, Germany, Hospital Universitari Mutua de Terrassa Spain 18. CURRENT MANAGEMENT OF PATIENTS HOSPITALIZED WITH COMPLICATED SKIN AND SOFT TISSUE INFECTIONS ACROSS EUROPE (2010–2011): ASSESSMENT OF PATIENTS WITH SURGICAL SITE INFECTION (RETROSPECTIVE STUDY TO ASSESS THE CLINICAL MANAGEMENT OF PATIENTS WITH MODERATE-TO-SEVERE CSSTI OR CAP INFECTIONS IN THE HOSPITAL SETTING [REACH] STUDY)

Background: Surgical site infections represent a significant burden in terms of patient morbidity and cost to health services worldwide. Outcomes and resource use are presented for surgical site infections recorded in REACH - a retrospective, observational cohort study designed to provide data on current clinical management of patients hospitalized with complicated skin and soft tissue infections (cSSTI) in European hospitals (NCT01293435).

Methods: Data were collected from 129 sites in ten European countries. The population comprised patients ≥18 years hospitalized between March 2010 and February 2011 with a cSSTI requiring intravenous antibiotic treatment. Variables were collected via an electronic Case Report Form.

Results: Of the total population (N=1996), 12.6% (n=252) of patients diagnosed with cSSTI had surgical site infections. The majority of these patients had been previously hospitalized (56.0%; n=141) or had invasive surgery (60.3%; n=152) in the 3 months prior to index visit, compared with 20.9% (n=418) and 14.0% (n=279) in the total population, respectively. Microbiological diagnosis (n=192) was similar to the total population, 65.6% (n=126) being infected with Gram-positive cocci; 65 Staphylococcus aureus infections (51.6%) and of those, 20 (30.8%) were methicillin-resistant. A further 40.6% (n=78) had Gram-negative pathogens.

Conclusions: Patients hospitalized with cSSTI resulting from surgery often experience complications, such as treatment failure to initial therapy, and require further surgery, increasing length of hospital stay and placing increased burden on hospital resources. These data highlight the need for reassessment of management regimens for this vulnerable patient group.

1 Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 2 Biomedical Research Center, Zhongshan Hospital, Fudan University, Shanghai, China 22. DYNAMIC CHANGES OF PERIPHERAL REGULATORY B CELLS IN PATIENTS WITH HBV RELATED HEPATOCELLULAR CARCINOMA DURING PERIOPERATIVE PERIOD

Background: Regulatory B cells (Bregs) have been proved to be critical in the modulation of immune responses of chronic inflammatory states and cancer microenvironment. However alterations of Bregs of patients with Hepatitis B (HBV) related hepatocellular carcinoma (HCC) remain unclear.

Aim: We investigated perioperative alterations of peripheral Bregs in HBV related HCC patients to reveal the relationship between Bregs and its clinical implications.

Methods: We have studied 23 patients with HBV related HCC and 14 controls, including patients with chronic HBV infection (CHB) and healthy donors. Frequency of peripheral IL-10+ CD19+ Bregs was measured by flow cytometry before, and after surgery. Clinical informatics of HCC patients was then collected using Digital Evaluation Score System for assessing disease severity. Finally, correlations between digitalized clinical features and kinetics of circulating Bregs were analyzed.

Results: Frequency of Bregs in CHB patients was higher than healthy donors. Preoperative level of Bregs in HCC patients was significantly lower than both control groups, but increased right after surgery (P<0.05). It was even higher than CHB patients about 7 days after surgery (P<0.05). Frequency of circulating Bregs was correlated with HBV related features including HBeAg and HBV DNA copy number.

Conclusions: Bregs were associated with active HBV infection, frequencies of peripheral Bregs in HBV related HCC patients increased after surgery. These results suggest that Bregs may play a role in the generation of HCC in patients with HBV infection opening a novel pathway to study immunopathogenesis of HBV related HCC.

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Frequencies of peripheral regulatory B cells of different study groups.

Frequencies of peripheral regulatory B cells were analyzed in the healthy donors(Healthy), patients with chronic HBV infection (CHB), and patients with HBV related hepatocellular carcinoma (HCC) before surgery (HCCb), 1-2 days (HCCa1) or about 7 days (HCCa7) after surgery. Frequency of IL 10⁺CD19⁺ cells of total CD19⁺ B cells in the peripheral blood (B). The mean±SEM is shown,* and** stand for P<0.05 and 0.01, respectively.

1 University of Amsterdam 2 Albert Schweitzer Ziekenhuis 23. ANTIBIOTICS RELATED ADVERSE DRUG EVENTS IN SURGICAL PATIENTS

Background: Medication related problems are a considerable cause of morbidity and mortality in hospitalized surgical patients. In contrast with other hospitalized patients, such as general medical patients, patients undergoing a surgical procedure are exposed to multiple medication changes associated with the surgical intervention. One of these medications is antibiotics, a great proportion of adverse drug events (ADEs) in hospitalized are attributed to these drugs. Another problem in prescribing antibiotics is intolerance or allergies for the drug.

Aim: The aim of this study is to determine the proportion of ADEs attributable to antibiotics and the incidence of allergies for antibiotics in surgical patients.

Methods: A multicentre study was performed in seven surgical units in three different hospitals: One university hospital and two teaching hospitals. Elective surgical patients with a hospital stay longer than 48 hours were included, ADEs were determined using chart review and an expert panel.

Results: During the study period, 567 patients were included, 49% male, mean age 62 years. Medication allergies were described in 87 of 545 patients (18.6%); in 51 patients (9.4%) there was an allergy for antibiotics, most frequently for penicillin. We found 156 ADEs in 130 of the 567 patients. Antibiotics were attributable to 4 (2.6%) of these ADEs, one ADE was preventable: a rash caused by ciproxin in a patient with a known allergy.

Conclusions: In surgical patients, antibiotics account for only a small proportion of ADEs; nevertheless caution and a good alert system is needed in patients with a known allergy for antibiotics.

1 Academical Medical Center, Amsterdam, Department of Surgery 2 St. Antonius Hospital 3 Department of Gastroenterology and Hepatology, Netherlands 24. SYSTEMATIC REVIEW AND META-ANALYSIS OF SOMATOSTATIN ANALOG FOR THE TREATMENT OF PANCREATIC FISTULA

Background: Somatostatin analog are used for the treatment of pancreatic fistula designed to achieve fistula closure or reduction of output.

Aim: Trials comparing the effect of current standard management with standard management including somatostatin analog were identified to evaluate the effect of somatostatin on closure rate and time to pancreatic fistula closure.

Methods: PubMed, EMBASE, and Cochrane databases were systematically searched for relevant articles followed by hand searching of reference lists. Data on patient recruitment, intervention, and outcome were extracted and meta-analysis performed where reasonable.

Results: Seven randomized controlled trials met the inclusion criteria and included a total of 297 patients with fistulas of the gastrointestinal tract; of these, 102 patients had fistulas of pancreatic origin. Pooling of results for closure rate showed no significant difference between patients treated with somatostatin analog compared with controls, OR 1.68 (0.52–5.43). Due to inconsistent descriptions, pooling of results was not possible for other endpoints, such as time to closure.

Conclusions: There is no solid evidence that somatostatin analog result in a higher closure rate of pancreatic fistula compared with other treatments.

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1 Lund University, Sweden 2 Milano-Bicocca University, Italy 3 Marien-Krankenhaus Bergisch Gladbach, Germany 28. FAST-TRACK SURGERY: WHAT IS THE PROCEDURE-SPECIFIC EVIDENCE?

Background: Fast-track (FT) surgery can be defined as a coordinated perioperative approach aimed at reducing surgical stress and facilitating early recovery.

Aim: To review the literature on the procedure-specific application of FT surgery.

Methods: PubMed was searched for randomized controlled trials (RCTs), quasi-RCTs, cohort studies, case-control studies and case series. The following key words were used: fast-track, enhanced recovery, accelerated rehabilitation and multimodal optimization. Trials documenting a minimum of 4 FT components were selected. Non-English language articles were excluded. One of the authors reviewed and abstracted the following data: first author, year of publication, study population, study design, length of stay, and major findings.

Results: Most studies (n=132) investigated the effects of FT in colorectal surgery. The remainder dealt with orthopedic surgery (n=42), hepatopancreaticobiliary surgery (n=17), urological surgery (n=17), upper gastrointestinal surgery (n=15), gynecological surgery (n=14), vascular surgery (n=10), thoracic surgery (n=8), endocrine surgery (n=5), breast surgery (n=4), pediatric surgery (n=3) and hernia repair (n=2). Overall quality of included studies was moderate, and there was considerable heterogeneity in the number of included FT elements. However, FT surgery was safe and feasible and demonstrated a clear benefit through the different procedures/specialties where the concept has been implemented.

Conclusions: The principles of FT surgery can be applied in most organ-specific procedures. Standardized protocols should be provided on a procedure-specific basis.

1 Institute of Biomedicine (IBIOMED) and CIBERehd, University of León, Spain 2 Laboratorio de Hepatologia Experimental Fisiologia HCPA/UFRGS, Porto Alegre, Brazil 2 Hospital of León, Spain 31. QUERCETIN ATTENUATES METHIONINE AND CHOLINE-DEFICIENT DIET-INDUCED STEATOHEPATITIS IN C57BL/6 MICE

Background: Nonalcoholic steatohepatitis (NASH) is a metabolic condition characterized by lipid accumulation in hepatocytes, inflammatory infiltration and fibrosis. Flavonoids have demonstrated a high therapeutic potential in various pathologies and a protective role in inflammatory processes. Quercetin is the major flavonoid found in the human diet.

Aim: This study aims to elucidate the effects of quercetin on inflammatory status and expression of pro-fibrogenic factors in a nutritional model of NASH.

Methods: Feeding a methionine-choline-deficient (MCD) diet to rodents reproducibly elicits NASH with fibrosis mimicking the severe form of NASH that occurs in some humans. We used C57BL/6 males divided into four experimental groups (n=12): control, NASH, quercetin-treated control, and quercetin-treated NASH mice. Quercetin (50 mg/kg) was administered intragastrically for 4 weeks.

Results: Quercetin significantly reduced gross damage and histopatological scores in the liver of treated NASH mice. Animals in the NASH group showed a marked increase of mRNA levels of tumour necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), transforming growth factor-beta (TGF-beta), Smad3, and alpha-smooth muscle actin (alpha-SMA). Expression of these inflammatory and fibrogenic markers were inhibited by administration of quercetin.

Conclusions: In summary, this study indicates that quercetin treatment prevents inflammation and fibrosis in a rodent model of NASH. This result supports that trials of quercetin may be reasonable in patients with established liver disease and inflammation.

1 Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) and Institute of Biomedicine (IBIOMED), University of León, Spain 2 Institute of Biomedicine (IBIOMED), University of León, Spain 3 Laboratory of Experimental Hepatology and Physiology, Porto Alegre Clinical Hospital, Federal University of Rio Grande do Sul, Porto Alegre, Brazil and Institute of Biomedicine (IBIOMED), University of León, Spain 4 Universitary Hospital of León and Institute of Biomedicine (IBIOMED), University of León, Spain 32. GLUTAMINE TREATMENT ATTENUATES ENDOPLASMIC RETICULUM AND APOPTOSIS STRESS IN TNBS-INDUCED COLITIS

Background: Inflammatory bowel diseases result from complex interactions among many factors, including overproduction of proinflammatory cytokines and reactive oxygen mediators, induced endoplasmic reticulum (ER) stress response, and apoptosis.

Aim: To investigate the ability of glutamine to reduce ER stress and apoptosis in a model of experimental colitis.

Methods: Colitis was induced in male Wistar rats by intracolonic administration of 30 mg of 2,4,6- trinitrobenzene-sulfonic-acid (TNBS). Glutamine (25mg/dL) was given by rectal route daily for 2 or 7 d. Rats were killed at 2 or 7 d and the distal 8 cm of the colon was collected.

Results: Both oxidative (TBARS concentration and oxidized/reduced glutathione ratio) and ER stress markers (CHOP, BiP, calpain 1 and caspase-12 expression) increased significantly within 48 h of TNBS instillation, and glutamine attenuated the extent of the changes. Colonic phospho-JNK and PARP-1 expression was also significantly higher in TNBS-treated rats compared to the control group, and treatment with glutamine significantly decreased JNK phosphorylation and PARP-1 proteolysis. TNBS instillation resulted in a significant increase in p53 and cytochrome c expression, and a reduced Bcl-xL expression and Bax/Bcl-2 ratio. These effects were significantly inhibited by glutamine. Treatment with glutamine also resulted in significant decreases of caspase-9, caspase-8, and caspase-3.

Conclusions: In addition to the antioxidant and anti-inflammatory properties of glutamine, data indicated that protection against damage in TNBS-induced colitis might be partly mediated by early inhibition of the ER stress response and anti-apoptotic effects.

1 Department of Abdominal Surgery, Helsinki University Central Hospital 2 Protein Chemistry Unit, Biomedicum Helsinki 3 Department of Vascular Surgery, Helsinki University Central Hospital, Finland 33. A COMPARISON OF THE PLASMA PROTEOME OF PATIENTS WITH APPENDICITIS, MESENTERIAL ISCHEMIA, AND SECONDARY PERITONITIS

Background: The acute abdomen is a diagnostic challenge and acute mesenterial ischemia is particularly dependent on an expedient diagnosis for optimal treatment.

Aim: Samples from patients with confirmed appendicitis, secondary peritonitis, or mesenterial ischemia were analyzed by LC MS/MS and the resultant plasma proteome profiles were compared for identification of peritonitis and ischemia-specific molecular determinants.

Methods: Plasma samples were subjected to depletion of albumin, IgG, antitrypsin, IgA, transferrin, haptoglobin, and fibrinogen, trypsin-digested and analyzed by LC MS/MS consisting of nano-Acquity UPLC coupled to a Synapt G2 HDMS mass spectrometer (Waters, UK). ProteinLynxGlobalServer (PLGS) version 2.4v software was used for the processing of raw data and protein database searching. Results were interpreted in terms of PLGS Mowse score protein readouts for peptide hits.

Results: To date, 10 patients have been analyzed: Six with appendicitis, three with peritonitis, and one with mesenterial ischemia. All patient groups had higher levels of C-reactive protein (CRP) and serum amyloid A (SAA) as compared to controls. Peptides detected specifically in peritonitis samples included Light chain of factor I (495.94 vs. 0 mean scores) and leucine-rich alpha 2 glycoprotein (595.45 vs. 108.06 mean scores). In contrast, the mesenterial ischemia sample displayed a divergent proteome that included elevated levels of complement component 4 binding protein (760.21 vs. 0 mean score) and low levels of Apo-E (300.11 vs. 22,539.8 mean score).

Conclusions: High-throughput profiling of the plasmaproteome in patients with an acute abdomen displays diverging proteomic profiles for different etiologies.

1 Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) and Institute of Biomedicine, University of León 2 Department of Surgery II, Complejo Asistencial Universitario de León, Hospital of León 3 Department of Oncology, Complejo Asistencial Universitario de León, Hospital of León, Spain 34. PPI-2458 ADMINISTRATION ON HEPG2 HEPATOCARCINOMA CELLS: INDUCTION OF STAT3 AND INFLUENCE ON CYTOKINES AND CELL CYCLE

Background: PPI-2458, a fumagillin derivative, has been tested in different tumor cells types. In HepG2 liver cancer cells this drug has demonstrated its efficacy reducing cell viability, inducing cycle progression and apoptosis.

Aim: We have investigated the effect of PPI-2458 on STAT3 pathway, its relation with cell cycle control and cytokine release on HepG2 hepatocarcinoma cells.

Methods: HepG2 cells were treated with PPI-2458 at the concentration of 10 nM at different times (2-6 days). Cell viability was determined by MTT assay. Moreover, expression of the different markers was analyzed by Western blot and RT-qPCR.

Results: Treatment with PPI-2458 resulted in a marked decrease of cell viability reaching a maximum in cells treated for 6 days. The inhibition on cell viability was accompanied by an increase in phospho-STAT3 in association with upregulation of cyclin D1 and P21 protein levels. Inhibition of STAT3 resulted in a marked decrease of cyclin D1 and P21. Furthermore, PPI-2458 induced the expression of inflammatory cytokines such as TNFα, IL-1β and VEGF. STAT3 inhibition did not modify TNF-α mRNA levels. However, IL-1β mRNA levels were augmented, whereas VEGF levels were decreased by STAT3 inhibition

Conclusions: PPI-2458 is able to induce an increase on phospho STAT3 protein levels, which could, at least in part, drive the expression of P21 and cyclin D1. In our experiments, STAT3 seems to be able to regulate VEGF and IL-1β transcription, but further investigations are necessary to elucidate the precise mechanism involved.

1 Centro de Investigación Biomédica en Red: Enfermedades Hepáticas y Digestivas (CIBERehd), and Institute of Biomedicine, University of León 2 Department of Surgery II, Complejo Asistencial Universitario de León, Hospital of León, Spain 3 I Department of Internal Medicine, University Medical Center, Johannes-Gutenberg-University, Mainz, Germany 35. MELATONIN INDUCES APOPTOSIS IN HEPG2 HEPATOCARCINOMA CELLS THROUGH TRANSCRIPTIONAL REGULATION OF BIM BY FOXO3A

Background: Hepatocellular carcinoma (HCC) is diagnosed in more than half a million people worldwide per year. Aggressive surgery or liver transplant are the only successful treatments available. Advances in understanding proliferation and apoptosis processes are needed to develop effective therapies. We have previously demonstrated that melatonin administration induces cycle arrest and apoptosis in HCC, but the precise pathways involved remain unclear. FoxO transcription factors play an important role in tumor suppression up-regulating target genes such as the pro-apoptotic protein Bim.

Aim: In line with these findings, we focused our study on the FoxO3a regulation of Bim after melatonin treatment.

Methods: HepG2 HCC cells were treated with 1000 and 2000 μM melatonin concentration. Expression of pro-apoptotic gene Bim was analyzed by qRT-PCR and Western Blot. FoxO3a activation was determined by luciferase reporter gene assay in transfected HepG2 cells, and its phosphorylation status by Western Blot. Nuclear translocation of FoxO3a was visualized by immunofluorescence.

Results: Both doses resulted in a significant induction of Bim at mRNA and protein levels, and increased FoxO3a transcriptional activity. Furthermore, melatonin was able to decrease the phosphorylated forms of FoxO3a at Thr32 and Ser253, increasing total FoxO3a. Dephosphorylation at these specific sites has been associated with changes on the FoxO3a subcellular location, to promote its transcriptional activity.

Conclusions: Together these data confirm that Bim plays a significant role in melatonin-induced apoptosis, most likely thought FoxO3a is a transcription factor in HepG2 cells, suggesting its safe use in HCC treatment, at least as a coadyuvant.

1 Institute of Biomedicine (IBIOMED) and CIBERehd. University of León 2 Department of Animal Health, University of León 3 Hospital of León, Spain 36. PROTECTIVE EFFECT OF MELATONIN IN AN ANIMAL MODEL OF VIRALLY INDUCED FULMINANT HEPATIC FAILURE

Background: Impaired liver regeneration is one of the most critical issues in the prognosis of fulminant hepatic failure (FHF).

Aim: To investigate the effect of melatonin on inflammatory and regenerative response in an animal model of FHF of viral origin.

Methods: Rabbits were experimentally infected with 20,000 hemagglutination units of a rabbit hemorrhagic disease virus (RHDV) isolate and received melatonin (10 and 20 mg/kg) at 0, 12, and 24 h postinfection.

Results: RHDV infection induced an inflammatory response in the liver, with increased expression of reactive C protein (CRP), interleukin (IL)-1beta, IL-6, and tumour necrosis factor (TNF). These effects were attenuated by melatonin in a concentration-dependent manner. In addition, melatonin treatment also resulted in a reduced expression of toll-like receptor (TLR)4 and matrix metalloproteinase (MMP)9. RHDV infection induced an inhibition of the hepatic regenerative/proliferative response, with a reduced expression of hepatocyte growth factor (HGF), epidermal growth factor (EGF), platelet-derived growth factor (PDGF)B, and vascular endothelial growth factor (VEGF) that were prevented by melatonin administration. Pro-regenerative effects of melatonin were related to a reduced expression of phosphorylated Janus kinase (JNK) expression and enhanced expressions of extracellular mitogen-activated protein kinase (ERK) and signal transducer and activator of transcription (STAT)3.

Conclusions: Our findings show that anti-inflammatory effects and stimulation of regenerative mechanisms contribute to the beneficial effects of melatonin in rabbits with experimental infection by RHDV, and support a potential hepatoprotective role of melatonin in FHF.

1 Department of Infection Control, Taipei Veterans General Hospital, Department of Nursing, Taipei Veterans General Hospital, Taipei 2 Taipei City Hospital, Branch for Women and Children, Taipei 2 Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan 38. ANTIBIOTIC-RESISTANT ORGANISMS AND ATTRIBUTABLE MORTALITY OF SURGICAL SITE INFECTION

Background: Surgical site infections (SSIs) are a real risk associated with any surgical procedure and its impact on morbidity and mortality, particularly in patients with antimicrobial-resistant pathogen SSIs.

Aim: The aim of this study was to identify the association between nosocomial SSIs and attributable mortality.

Methods: A retrospective cohort study was conducted in a 2,900-bed tertiary refer medical center in Taiwan. All patients who received a surgical procedure that had developed SSIs from 2009 to 2010 were eligible. The definitions of the Centers for Disease Control and Prevention were used to categorize superficial incision site, deep incision space, or organ space.

Results: Seven hundred and sixty-nine patients with a SSI were identified. The incidence rate was 8.1%. The frequent sites were superficial incision site (45%), organ space (32%), and deep incision space (23%). The most common organisms were Staphylococcus aureus (11.6%), Pseudomonas aeruginosa (7.1%), and Enterococcus spp. (6.4%). The most common antibiotic-resistant organisms were Klebsiella pneumonia and Escherichia coli producing extended spectrum beta-lactamase (ESBL) 3.1%. After controlling prognostic factors for mortality, ESBL (odds ratio [OR] 3.45; 95% confidence interval [CI] 1.32, 9.04), length of stay before onset of SSI (OR 1.009; CI 1.003, 1.015), and age (OR 1.027; CI 1.010, 1.044) were independent factors.

Conclusions: S. aureus was the most common organisms of SSIs. K. pneumonia and E. coli ESBL SSIs were the important prognostic factors after adjusting for covariates. This emphasizes the importance of continuous efforts in the prevention of SSIs, especially antimicrobial resistance.

1 Ministry of Defense Health Centre 2 Department of Urology, Péterfy Hospital 3 Department of Aerospace Medicine, University of Szeged, Hungary 40. CAN WE PREDICT POST-OPERATIVE INFECTIONS?

Background: Many patients develop infections following operations. Decreased immune competence has been demonstrated in acute neurological conditions.

Aim: A strong cytokine mediated anti-inflammatory response was observed in stroke patients at infection, although infection due to the decreased pro-inflammatory mediators can be expected as well. To investigate this question the following experiment was performed.

Methods: Ten urinary bladder cancer patients with radical cystectomy and lymphadenectomy were studied. Blood samples were taken on Day 0 before and Day 1, 3, 6, 9, and 14 after operation as well as on Day 30, 60, 90, and 270 during follow up.

TNF, soluble TNF receptor I, and IL-6 levels in sera were determined by HS ELISA and/or ELISA. Plasma ACTH and cortisol values were measured by RIA kits.

Results: From 10 urinary bladder cancer patients five deep wound and urine infections were found in 14 days and three urine infections in 30 days after surgery, all survived. All patients were bacterially contaminated. On Day 0 the circulating TNF values were lower in infected patients. TNF started to increase from Day 3 till Day 9, never reaching values of uneventful healing group. Soluble TNF receptor I, IL-6, ACTH, and cortisol concentrations did not demonstrate any difference on Day 0, however, from Day 1 started to increase transiently, reaching higher levels in septic patients.

Conclusions: An excessive decrease in pro-inflammatory response is a key facilitating factor for the development of infection. Thus, measuring serum TNF levels before and after operations can predict the outcome.

1 Department of General Surgery, La Princesa University Hospital, Madrid 1 Department of Clinical Microbiology, La Princesa University Hospital, Madrid, Spain 43. DIVERTICULAR DISEASE COMPLICATED BY FISTULAE: WHAT CAN WE LEARN FROM THESE PATIENTS?

Background: The incidence of fistulae in patients with diverticular disease, the most common cause of colovesical fistula, is accepted to be around 2%. Symptoms include suprapubic pain, dysuria, and frequency and chronic urinary tract infections (UTI), usually treated with various courses of antibiotics. Fecaluria can be considered pathognomonic.

Aim: To present our experience in the management of vesicoenteric fistulae secondary to diverticular disease.

Methods: Descriptive, retrospective study of patients with vesicoenteric fistulae in our institution in the last 5 years. Evaluation of the clinical presentation, diagnosis and treatment.

Results: Six patients presented colovesical fistulae, and one a rectovesical fistula. Male–female ratio was 3:4. Mean age: 71 years. Patients' data are shown in the table 1 below. All patients underwent elective open surgery. The standard procedure for colovesical fistulae was a sigmoidectomy and T-T colorectal anastomosis. Four patients needed primary repair of the bladder. A rectal stump resection, extended right hemicolectomy and ileo-colic anastomosis was performed on the patient with the rectovesical fistula.

Conclusions: A better knowledge of the characteristics and presentation of diverticular disease complicated by fistulae can help to improve our management of these patients. Surgical resection of the involved segment of colon and primary anastomosis is the treatment of choice.

1 University Hospital of León, Ophthalmology Service 2 University Hospital of León. Otolaryngology Service, Spain 44. SUBPERIOSTEAL ORBITAL ABSCESS AFTER MAXILLARY AND ETHMOIDAL ANTRECTOMY FOR CHRONIC SINUSITIS

Background: Chronic sinusitis is usually associated with a small ostium of drainage. The maxillary antrectomy improves mucus evacuation and prevents infection. However, if surgical technique is not correct and the medial orbital wall is broken, it can produce a subperiosteal orbital abscess.

Aim: This surgical infection can threaten visual acuity and even the life of the patient.

Methods: A 32-year-old female patient with chronic sinusitis underwent antrectomy in an other clinical center by endoscopic sinus surgery in her right maxillary and ethmoidal sinus. The following three days, despite being treated with amoxicillin/clavulanic acid, she developed temperature, headache, proptosis, and visual acuity loss in her right eye so she was referred to our hospital. When she arrived at our hospital her visual acuity was no light perception in her right eye. Orbital computed tomography (CT) revealed a subperiosteal abscess in the medial orbital wall and apex. She was admitted and underwent an emergency medial anterior orbitotomy to drain the subperiosteal abscess. We initiated endovenous treatment with linezolid and meropenem.

Results: Culture of abscess fluid showed growth of methicillin-resistant Staphylococcus aureus. On following days, her general condition improved but she did not recover vision.

Conclusions: Paranasal sinuses surgery is a possible local infection source. The proximity of these cavities to the orbit allows the passage of microorganisms into the orbit. Choosing the most accurate antibiotic therapy and making a prompt orbital CT and drainage of abscess are the treatment of this infection with an important morbility.

1 Department of General Surgery, La Princesa University Hospital, Madrid 2 Department of Clinical Microbiology, La Princesa University Hospital, Madrid 3 Department of Preventive Medicine, La Princesa University Hospital, Madrid, Spain 45. SURGICAL INFECTION BY MULTI-RESISTANT PSEUDOMONAS AERUGINOSA AFTER EVENTROPLASTY: IS REMOVAL OF THE MESH MANDATORY?

Background: Infections by multidrug-resistant P. aeruginosa are increasingly being reported in the surgical setting. Management can be complicated, with almost no choice of antibiotics left for treatment.

Aim: To describe a case of soft tissue infection by P. aeruginosa involving mesh, the clinical management, and outcome.

Methods: A 62-year-old woman, with a history of diabetes, high blood pressure, chronic kidney disease, thrombotic CVA, arthritis, gout, and gastric bypass, presented with recurrent cholangitis. She had previously undergone cholecystectomy and choledochoduodenostomy. She now presented stenosis of the latter, residual choledocholithiasis, and a ventral hernia. An elective operation was performed: Laparotomy, extraction of residual calculi, hepaticojejunostomy, and eventroplasty. After surgery she presented acute renal failure, polyarthritis, and surgical wound infection. Cultures were positive for P. aeruginosa, only susceptible to Amikacin.

Results: Despite renal failure, intravenous treatment with Amikacin was started with a strict dose adjustment and blood-level controls. The presence of a mesh made the situation more challenging. Exhaustive cleansing and dressing of the wound, avoiding exposure of the mesh, was performed twice a day. Eventually, the infection was controlled, and the patient was discharged on the 47th postoperative day.

Conclusions: Management of patients with infections by multiresistant pathogens can be challenging for the surgeon: They can complicate the postoperative course and increase hospital stay and costs. An early diagnosis and targeted antibiotic therapy are essential, and can avoid mesh removal in some patients.

1 Department of General Surgery, La Princesa University Hospital, Madrid 2 Department of Clinical Microbiology, La Princesa University Hospital, Madrid, Spain 46. NECROTIZING FASCIITIS OF THE ABDOMINAL WALL: WHAT'S THE KEY TO A SUCCESSFUL TREATMENT?

Background: Necrotizing fasciitis is an uncommon but severe condition, which causes a rapid infection of the subcutaneous tissue and fascia, resulting in necrosis, sepsis, and death if not treated promptly and aggressively.

Aim: We present the case of a patient with necrotizing fasciitis of the abdominal wall after an emergency Hartmann's procedure.

Methods: An obese, 75-year-old woman, with history of breast cancer and previous diverticulitis, presented with an acute large bowel obstruction. CT images showed a strictured segment of sigmoid colon, with concentric wall thickening, described as inflammatory versus a possible malignancy. After a failed attempt of conservative treatment and colonic stenting she underwent emergency sigmoidectomy and colostomy.

Results: Two days after surgery she developed extensive erythema and cellulitis of the left flank, with an increase in sepsis markers and severe pain. CT imaging showed subcutaneous and fascial thickening, with liquid collections. The patient underwent emergency surgery with fasciotomy and debridement, intensive resuscitation therapy, and intravenous broad-spectrum antibiotics (Daptomycin, Meropenem, and Metronidazole). Cultures were positive for E. coli, Ampicillin-resistant E. faecium and Streptococci. A second intervention was performed for new debridement. The outcome was satisfactory. She was discharged 59 days after admission.

Conclusions: Necrotizing fasciitis demands early and aggressive surgery, intensive therapy, and antibiotics. Despite the poor prognosis, in some cases this treatment can be successful and achieve survival.

1 First Department of Surgery, Tzaneion General Hospital, Piraeus 2 Department of Radiology, Tzaneion General Hospital, Piraeus, Greece 47. INFECTED PANCREATIC NECROSIS SUCCESSFULLY MANAGED NON-OPERATIVELY IN AN ELDERLY PATIENT: A CASE REPORT

Background: Infected pancreatic necrosis in the context of severe pancreatitis is associated with high morbidity and mortality and is considered as a straightforward indication for debridement.

Aim: To present an elderly patient with infected pancreatic necrosis and abscess successfully managed non-operatively.

Methods: A 76-year-old male patient was admitted for acute gallstones pancreatitis. An abdominal computed tomography (CT) demonstrated pancreatic swelling, necrosis of the neck of the pancreas approximately 1.5 cm and peripancreatic fluid collections (Balthazar grade E and <30% necrosis, resulting in a CT severity index of 6 points). Laboratory tests showed an increased creatinine 1.8 mg% and C-reactive protein 316 mg%. An APACHE-II score of 8 points and Marshall score of 2 points were calculated. A second abdominal CT after four weeks demonstrated Balthazar grade E and >60% necrosis, with the presence of air in the lesser sac. Due to relapse of high-grade fevers a minimally invasive approach was decided on.

Results: Under local anesthesia and CT guidance a 7-Fr pigtail catheter was inserted in the pancreatic abscess. In the subsequent 10 days a total of approximately 1200 cc of pus was drained via the catheter and the patient recovered. After three weeks a second pigtail catheter was inserted in an adjacent area of the pancreatic abscess and the patient had an uneventful course and recovered completely. After 12 weeks from initial attack the patient was discharged.

Conclusions: Minimally invasive approaches may have a successful outcome without the need for debridement of necrotic material.

1 University Hospital of León, Ophthalmology Service 2 University Hospital of León, Otolaryngoloy Service, Spain 48. ACUTE DACRYOCYSTITIS AFTER DACRYOCYSTECTOMY IN PATIENT WITH CHRONIC NASOSINUSAL POLYPOSIS

Background: Dacryocystectomy (DCT) is the best possible procedure in patients with dacryocystitis and dry eye or underlying medical conditions that might predispose to nasal scarring after standard dacryocystorhinostomy. Although DCT has a high rate of success removing the infection, a recurrence can develop in some cases.

Methods: A 73-year-old female patient underwent simultaneously endoscopic sinus surgery for naso-sinusal polyps and left DCT for acute dacryocystytis. Her past medical history included morbid obesity, diabetes mellitus type 2, arterial hypertension, bronchial asthma, angina pectoris, and chronic nasal polyposis that required several endoscopic operations. The patient had an important facial deformity caused by spreading of her nasal cavity by polyps. A big lacrimal sac that spread the lacrimal fossa bones was observed during dacryocystectomy. Lacrimal sac mucous was removed and superior and inferior lacrimal puncta were coagulated. Despite the initial success, the patient developed a new dacryocystitis in the left side 12 months after the first lacrimal surgery, so she underwent a new DCT. After 20 months of followup she did not develop a recurrence.

Results:

Conclusions: The authors report on a patient with several risk factors to suffer an infection. The initial DCT failed as a new dacryocystitis was developed. Although successful rate of DCT is very high, close to 95%, her general condition (obesity and diabetes) and her local conditions (enlarge lacrimal fossa and chronic nasal polyposis) promoted the formation of a new lacrimal sac and a new infection.