Evidence-Based Strategies for the Treatment of Peritoneal Malignancies during Health Care Resource Restriction: The COVID-19 Pandemic.

Background: The COVID-19 pandemic has put enormous pressure on hospital resources, and has affected all aspects of patient care. As operative volumes decrease, cancer surgeries must be triaged and prioritized with careful thought and attention to ensure maximal benefit for the maximum number of patients. Peritoneal malignancies present a unique challenge, as surgical management can be resource intensive, but patients have limited non-surgical treatment options. This review summarizes current data on outcomes and resource utilization to help inform decision-making and case prioritization in times of constrained health care resources. Methods: A rapid literature review was performed, examining surgical and non-surgical outcomes data for peritoneal malignancies. Narrative data synthesis was cross-referenced with relevant societal guidelines. Peritoneal malignancy surgeons and medical oncologists reviewed recommendations to establish a national perspective on case triage and mitigating treatment strategies. Results and Conclusions: Triage of peritoneal malignancies during this time of restricted health care resource is nuanced and requires multidisciplinary discussion with consideration of individual patient factors. Prioritization should be given to patients where delay may compromise resectability of disease, and where alternative treatment options are lacking. Mitigating strategies such as systemic chemotherapy and/or surgical deferral may be utilized with close surveillance for disease stability or progression, which may affect surgical urgency. Unique hospital capacity, and ability to manage the complex post-operative course for these patients must also be considered to ensure patient and system needs are aligned.

Laparoscopic Intragastric Resection: An Alternative Technique for Minimally Invasive Treatment of Gastric Submucosal Tumors.

OBJECTIVE: To present the technique for and early results of laparoscopic intragastric resection (LIGR). BACKGROUND: Treatment of confirmed or suspected submucosal gastric malignancies relies on clear margin resection, for which minimally invasive surgery is widely accepted. However, resection in some localization remains challenging. METHODS: We present the steps of LIGR for gastric submucosal tumors (GSMTs). We report the results of LIGR in consecutive patients operated at 2 institutions, including intraoperative, pathologic, 30-day major morbidity and mortality characteristics. RESULTS: After laparoscopic access to the abdominal cavity, cuffed gastric ports are placed to approximate the anterior gastric wall to the abdominal wall. A pneumogastrum is created. The tumor is resected in the submucosal plane and the deficit closed with intragastric suturing. Specimen extraction is performed perorally or through a gastrotomy site. In 8 proximal intraluminal GSMTs with median size of 3.1 cm (range: 1.8-6.0 cm), median operative time was 167.5 minutes (range: 120-300 mins). There was no major morbidity and no mortality. All resections were R0. CONCLUSIONS: We illustrate the technique of a novel, feasible, and safe minimally invasive approach to GSMTs. LIGR is an alternative to resect challenging GSMTs by limiting surgical invasiveness and preserving gastrointestinal function.

Laparoscopic versus open colonic resection for complicated diverticular disease in the emergency setting: a safe choice? A retrospective comparative cohort study.

BACKGROUND: We conducted a retrospective cohort study to compare the outcomes of laparoscopic colon resection (LCR) with open colon resection (OCR) for complicated diverticular disease (CDD) during emergent hospital admission. METHODS: Charts from all patients undergoing colon resection for CDD during emergent hospital admission at a single academic institution were reviewed. The primary outcomes were overall 30-day postoperative morbidity and mortality. RESULTS: From 2000 to 2010, 125 cases were retrieved (49 LCR and 86 OCR). Conversion rate was 5.1%. Overall morbidity significantly decreased with laparoscopic surgery compared with OCR. No mortality occurred with LCR. Prolonged ileus was less frequent (12.8% vs. 32.6%; P = .02), time to oral intake shorter (3 vs. 6 days; P < .01), and LOS shorter (5 vs. 8 days; P = .05) for LCR. CONCLUSIONS: In our series, in the patients selected, LCR for CDD during emergent hospital admission appears to be a safe procedure associated with decreased morbidity, time to oral intake, and LOS compared with OCR.

Transanal drainage to treat anastomotic leaks after low anterior resection for rectal cancer: a valuable option.

BACKGROUND: Anastomotic leaks after low anterior resection for rectal cancer remain a major cause of morbidity and mortality. Few studies have focused on their management, particularly on the technique of transanal drainage. OBJECTIVE: The aim of this study was to assess the short- and long-term outcomes according to the initial management of clinical leaks. DESIGN AND SETTINGS: This study is a retrospective review of a single institution experience. PATIENTS: All patients treated for a symptomatic anastomotic leak after low anterior resection for rectal cancer between January 2000 and March 2011 were included. MAIN OUTCOME MEASURES: The primary outcomes were mortality attributed to the leak, sepsis control, stoma closure rate, and functional results. RESULTS: A total of 37 patients (35 men/2 women) developed a symptomatic leak. Leaks were initially managed by transanal drainage in 16 patients, abdominal reintervention in 12 patients, and medical treatment in 9 patients. The only death attributed to the leak occurred in the abdominal reintervention group. In the transanal drainage group, antibiotics were administered for a median length of 9 days, and the drain was left in place for a median length of 30 days. One patient underwent percutaneous drainage of a collection in addition to transanal drainage, but no patient required abdominal reintervention. Of the treatment modalities applied, transanal drainage was associated with the highest stoma closure rate (93%), after a median postoperative time of 7 months. Complications observed after transanal drainage were anastomotic strictures in 33% and the creation of a permanent stoma due to poor function in 13%. LIMITATIONS: This study was limited by its nonrandomized retrospective design and the presence of selection bias. CONCLUSIONS: : For the management of low anastomotic leaks, transanal drainage allows preservation of the anastomosis and sepsis control with a high rate of ileostomy closure. It is a valuable option in patients with a diverting ileostomy.

Seizures and hyponatremia related to ethcathinone and methylone poisoning.

INTRODUCTION: We report a case of ethcathinone and methylone poisoning with severe clinical toxicity. This is to our knowledge the first case reported in the medical toxicology literature. CASE REPORT: A 22-year-old woman was brought to the emergency department following several episodes of tonicoclonic seizures, a few hours after ingesting "legal ecstasy". The patient needed intubation for recurrent seizures, and she was found to have severe hyponatremia (120 mmol/L) that was corrected with hypertonic saline. The patient's mental status improved rapidly, and she was extubated the day following her admission. However, she developed prolonged rhabdomyolysis (CK 34.537 U/L) that required a 6-day hospitalisation. DISCUSSION: The seizures and the hyponatremia may be explained by the MDMA-like characteristics of methylone that may induce inappropriate secretion of antidiuretic hormone mediated via the serotonin system. The combination of methylone and ethcatinone (both acting like serotonin reuptake inhibitors) might have contributed to neurologic manifestations compatible with serotonin toxicity, although our patient never had autonomic instability. Our patient had a prolonged period of rhabdomyolysis which may also be explained by excessive serotonin activity resulting in an increased motor hyperactivity. The public has to be aware of this growing health problem. Clinicians must report future cases of toxicity related to the use of cathinone synthetic derivatives in order to increase our knowledge of these substances.