Impact of Indocyanine Green Fluorescence Imaging on Lymphadenectomy Quality During Laparoscopic Distal Gastrectomy for Gastric Cancer (Greeneye): An Adaptative, Phase 2, Clinical Trial.

BACKGROUND: Indocyanine green (ICG)-guided lymphadenectomy using near-infrared visualization (NIR) may increase nodal yield during gastrectomy. The purpose of this study was to evaluate the clinical benefit of NIR visualization on the quality of D2 lymphadenectomy during laparoscopic distal gastrectomy. METHODS: This single-arm, open-label, Simon's two-stage, adaptive, phase 2 trial included patients who underwent laparoscopic distal gastrectomy for gastric adenocarcinoma. Endoscopic peritumoral injection of ICG was performed 24 ± 6 h before surgery. Intraoperatively, after standard D2 lymphadenectomy and specimen extraction, NIR was used for eventual completion lymphadenectomy. The primary endpoint was clinical benefit of NIR (i.e., at least one additional harvested station containing lymph nodes, with negative points for every harvested station with no lymph nodes at final pathology). RESULTS: We enrolled 18 patients (61% female, median age 69 years). With NIR, an extra 23 stations were harvested: 9 contained no lymph nodes, 12 contained nonmetastatic lymph nodes, and 2 contained metastatic lymph nodes. The most commonly visualized station with NIR were station 6 (8 patients) and 1 (4 patients). The total number of harvested nodes per patient was 32 (interquartile range [IQR] 26-41), with a median of 1 (IQR 0-1) additional lymph node after NIR. Overall, seven (39%) patients had a clinical benefit from NIR, of which two (11%) had one metastatic lymph node harvested with NIR. CONCLUSIONS: NIR visualization improves the quality of D2 lymphadenectomy in distal gastrectomy for gastric cancer. Considering the limited improve in the number of harvested lymph nodes, its real oncological benefit is still questionable.

Comparison between level 1 and level 2 trauma centers for the management of splenic blunt trauma.

INTRODUCTION: The management of blunt splenic trauma has evolved in the last years, from mainly operative approach to the non-operative management (NOM). The aim of this study is to investigate whether trauma center (TC) designation (level 1 and level 2) affects blunt splenic trauma management. METHODS: A retrospective analysis of blunt trauma patients with splenic injury admitted to 2 Italian TCs, Niguarda (level 1) and San Carlo Borromeo (level 2), was performed, receiving either NOM or emergency surgical treatment, from January 1, 2015 to December 31, 2020. Univariate comparison was performed between the two centers, and multivariate analysis was carried out to find predictive factors associated with NOM and splenectomy. RESULTS: 181 patients were included in the study, 134 from level 1 and 47 from level 2 TCs. The splenectomy/emergency laparotomy ratio was inferior at level 1 TC for high-grade splenic injuries (30.8% for level 1 and 100% for level 2), whose patients presented higher incidence of other injuries. Splenic NOM failure was registered in only one case (3.3%). At multivariate analysis, systolic pressure, spleen organ injury scale (OIS) and injury severity score (ISS) resulted significant predictive factors for NOM, and only spleen OIS was predictive factor for splenectomy (Odds Ratio 0.14, 0.04-0.49 CI 95%, P < .01). CONCLUSION: Both level 1 and 2 trauma centers demonstrated application of NOM with a high rate of success with some management difference in the treatment and outcome of patients with splenic injuries between the two types of TCs.

Comparison between level 1 and level 2 trauma centers for the management of splenic blunt trauma / Comparación entre los centros de trauma de nivel 1 y nivel 2 para el manejo del trauma cerrado esplénico

Introduction: The management of blunt splenic trauma has evolved in the last years, from mainly operative approach to the non-operative management (NOM). The aim of this study is to investigate whether trauma center (TC) designation (level 1 and level 2) affects blunt splenic trauma management. Methods: A retrospective analysis of blunt trauma patients with splenic injury admitted to 2 Italian TCs, Niguarda (level 1) and San Carlo Borromeo (level 2), was performed, receiving either NOM or emergency surgical treatment, from January 1, 2015 to December 31, 2020. Univariate comparison was performed between the two centers, and multivariate analysis was carried out to find predictive factors associated with NOM and splenectomy. Results: 181 patients were included in the study, 134 from level 1 and 47 from level 2 TCs. The splenectomy/emergency laparotomy ratio was inferior at level 1 TC for high-grade splenic injuries (30.8% for level 1 and 100% for level 2), whose patients presented higher incidence of other injuries. Splenic NOM failure was registered in only one case (3.3%). At multivariate analysis, systolic pressure, spleen organ injury scale (OIS) and injury severity score (ISS) resulted significant predictive factors for NOM, and only spleen OIS was predictive factor for splenectomy (Odds Ratio 0.14, 0.04–0.49 CI 95%, P < .01). Conclusion: Both level 1 and 2 trauma centers demonstrated application of NOM with a high rate of success with some management difference in the treatment and outcome of patients with splenic injuries between the two types of TCs. (AU)

Introducción: El manejo del traumatismo esplénico cerrado ha evolucionado en los últimos años, desde un abordaje mayoritariamente operatorio hasta el manejo no operatorio (NOM). El objetivo de este estudio es investigar si la designación de centro de trauma (CT) (nivel 1 y nivel 2) afecta el manejo del trauma esplénico contundente. Métodos: Se realizó un análisis retrospectivo de pacientes con trauma contuso con lesión esplénica ingresados ​​en los TC Italianos de Niguarda (nivel 1) y San Carlo Borromeo (nivel 2), que recibieron tratamiento NOM o quirúrgico de emergencia, desde el 1 de enero de 2015 al 31 de diciembre de 2020. Se realizó una comparación univariante entre los dos centros, y se llevó a cabo un análisis multivariante para encontrar factores predictivos asociados con NOM y esplenectomía. Resultados: Se incluyeron en el estudio 181 pacientes, 134 del nivel 1 y 47 del nivel 2 de CT. La relación esplenectomía/laparotomía de urgencia fue inferior en el TC de nivel 1 para las lesiones esplénicas de alto grado (30,8% para el nivel 1 y 100% para el nivel 2), cuyos pacientes presentaron mayor incidencia de otras lesiones. La falla NOM esplénica se registró solo en un caso (3,3%). En el análisis multivariado, la presión sistólica, la escala de lesión de órganos del bazo (OIS) y la puntuación de gravedad de la lesión (ISS) resultaron factores predictivos significativos para la NOM, y solo la OIS del bazo fue un factor predictivo para la esplenectomía (Odds Ratio 0.14, 0.04–0.49 IC 95%, P < ,01). Conclusión: Los centros de trauma de nivel 1 y 2 demostraron la aplicación de NOM con una alta tasa de éxito con alguna diferencia de manejo en el tratamiento y el resultado de los pacientes con lesiones esplénicas entre los dos tipos de TC. (AU)

Mediterranean spotted fever and hearing impairment: a rare complication.

Mediterranean spotted fever (MSF) is caused by Rickettsia conorii and transmitted by the brown dog tick Rhipicephalus sanguineus. It is prevalent in southern Europe, Africa and central Asia. The disease usually has a benign course and is characterized by fever, myalgia and a characteristic papular rash with an inoculation eschar ('tache noir') at the site of the tick bite. Severe forms of disease can have cardiac, neurologic or renal involvement. Nervous system complications are unusual and may develop in the early phase of disease or as a delayed complication. Neurological symptoms include headache and alterations of the level of consciousness, and some cases of meningoenchefalitis and Guillain-Barrè syndrome have been also reported. Peripheral nerve involvement is reported only in a limited number of case reports. We describe a case of Rickettsia conorii that was complicated with hearing loss and did not respond to specific treatment. Hearing loss is a rare event, but clinicians should be aware of this complication.